SRL Diagnostics report on International Women’s Day

March 8, 2022 Rekha Nair Health Comments Off on SRL Diagnostics report on International Women’s Day

March 2022: Mumbai: Ahead of International Women’s Day, SRL Diagnostics, and India’s leading diagnostic chain published a data analytics report on results of samples received for various tests from January 2015 to December 2021 at SRL Laboratories across the country. This report has been prepared basis retrospective data mining done on the results of top 7 tests undertaken by women. The report covers five major metro cities: Mumbai, Delhi, Bangalore, Kolkata, and Chennai.

The top 7 tests undertaken by women in terms of volume are Thyroid Stimulating Hormone, Creatinine, Hemoglobin, Random Blood Glucose, Cholesterol, Vitamin D and Calcium.

Speaking about the report, Mr. Anand. K, Chief Executive Officer, SRL Diagnostics said “Women are the primary care takers of families across the world. It is observed that women suffer from poor health outcomes and this has consequences not just for women but also for their families. Our study on 1.3 crore samples tested over 5 years across 5 metro cities show that women suffer from most common ailments including high blood sugar and cholesterol levels, poor kidney function, anemia, vitamin D deficiency and calcium deficiency. We have published this report to showcase data evidence that points to these conditions and deficiencies.” 

Dr. Abha Sabhikhi, Technical Director, SRL Diagnostics said “Women often tend to neglect their own nutrition and health needs and this is observed even in metro cities. Women bear the dual responsibility of being the primary caregivers at home in addition to their role in the professional sphere. This Women’s Day, we have analysed and published data so that more women can understand their risks and prioritise their own health and well-being. Regular monitoring of vital parameters, balanced nutrition, time for self-care and physical exercise is important.”

Table 1: Total number of samples tested across cities for top seven tests undertaken by women

Location Hemoglobin TSH Calcium Vitamin D Fasting Blood Sugar Cholesterol Creatinine
Mumbai 906860 1078291 218790 250209 524326 395139 1362444
Delhi 869388 708501 166596 182201 268728 231573 1503916
Bangalore 497479 512679 75062 60349 157685 172182 881740
Kolkata 254051 295439 47143 49237 152662 91384 506714
Chennai 122974 144613 17926 18187 53745 53923 190815
Grand Total 2650752 2739523 525517 560183 1157146 944201 4445629

 
HEMOGLOBIN TEST
The Hemoglobin test is one of the many parameters that is tested in CBC – that is a complete blood count or hematocrit. The hemoglobin test is of the utmost importance as IDA (Iron Deficiency Anemia) has been a huge public health problem in India. Estimates suggest that 20% of maternal deaths are directly related to anemia. The National Nutritional Anemia Prophylaxis Program was launched in 1970 in India to improve the status of IDA but it continues to be an underdiagnosed and underutilized problem. It is important to diagnose and correct anemia for overall health and well-being.

• In an analysis of Hemoglobin results in five cities, we found that over 55% of women who underwent the Hemoglobin test reported abnormal levels.
• In 2020, the first year of pandemic, Hemoglobin tests dropped by over 29% as access to testing was restricted due to lockdown and fear of visiting a health care centre for health needs. In 2021, despite an increase in tests, the volumes did not reach pre-pandemic levels.

Table 2: Analysis of Hemoglobin results in five cities

Hemoglobin Normal Abnormal Total Normal Abnormal
Mumbai 437047 469813 906860 48.19 51.81
Delhi 371654 497734 869388 42.75 57.25
Kolkata 86385 167666 254051 34.00 66.00
Bangalore 252548 244931 497479 50.77 49.23
Chennai 59504 63470 122974 48.39 51.61
Average 1207138 1443614 2650752 44.82 55.18

Table 2A: Covid-19 Impact on routine tests for women – Hemoglobin

Year Mumbai % Delhi % Kolkata % Bangalore % Chennai %
2015 115119 108191 29376 82912 20012
2016 120854 5% 131101 21% 32473 11% 74648 -10% 18715 -6%
2017 121793 1% 133547 2% 36111 11% 77863 4% 19081 2%
2018 135742 11% 142128 6% 39093 8% 70588 -9% 19416 2%
2019 145714 7% 133658 -6% 42712 9% 77499 10% 19359 0%
2020 110790 -24% 99725 -25% 31765 -26% 52170 -33% 12191 -37%
2021 156848 42% 121038 21% 42521 34% 61799 18% 14200 16%
Total 906860 869388 254051 497479   122974  

 

Table 2B: Age Group wise analysis of Hemoglobin results in five metro cities

Hemoglobin Mumbai Delhi Kolkata Bangalore Chennai
Age Group Normal Abnormal Normal Abnormal Normal Abnormal Normal Abnormal Normal Abnormal
0-15 25027 12811 58763 29756 5342 3416 17812 7343 4920 2402
16-30 102505 85699 84630 89552 21147 25405 75456 50994 21437 19712
31-45 124919 124846 89866 110490 23084 38580 69446 62084 15007 16553
46-60 108132 110489 76740 104951 20612 45297 48815 52465 10373 11301
61-85 74776 131729 59510 154013 15820 53367 39952 69370 7481 12712
85+ 1688 4239 2145 8972 380 1601 1067 2675 286 790
Total 437047 469813 371654 497734 86385 167666 252548 244931 59504 63470

 

Hemoglobin Mumbai Delhi Kolkata Bangalore Chennai
Age Group Normal Abnormal Normal Abnormal Normal Abnormal Normal Abnormal Normal Abnormal
0-15 66% 34% 66% 34% 61% 39% 71% 29% 67% 33%
16-30 54% 46% 49% 51% 45% 55% 60% 40% 52% 48%
31-45 50% 50% 45% 55% 37% 63% 53% 47% 48% 52%
46-60 49% 51% 42% 58% 31% 69% 48% 52% 48% 52%
61-85 36% 64% 28% 72% 23% 77% 37% 63% 37% 63%
85+ 28% 72% 19% 81% 19% 81% 29% 71% 27% 73%

 

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THYROID STIMULATING HORMONE

The Thyroid Stimulating Hormone is the most commonly ordered test to diagnose thyroid related disorders or to diagnose thyroid hormone imbalances. The TSH test may also be ordered along with Free T3 and Total T3 or Free T4 and Total T4.

  • In an analysis of TSH results in five cities, we found that over 25% of women who underwent the TSH test reported abnormal levels.
  • In 2020, the first year of pandemic, TSH tests dropped by over 35% as access to testing was restricted due to lockdown and fear of visiting a health care center for health needs. In 2021, despite an increase in tests, the volumes did not reach pre-pandemic levels.


Table 3: Analysis of TSH results in five cities

TSH Normal Abnormal Total Normal Abnormal
Mumbai 820044 258247 1078291 76.05 23.95
Delhi 531622 176879 708501 75.03 24.97
Kolkata 218477 76962 295439 73.95 26.05
Bangalore 386412 126267 512679 75.37 24.63
Chennai 120046 24567 144613 83.01 16.99
Average 2076601 662922 2739523 76.68 23.32

 

Table 3A: Covid-19 Impact on routine tests for women – Thyroid Stimulating Hormone

Year Mumbai % Delhi % Kolkata % Bangalore % Chennai %
2015 149020 105281 41275 99898 21795
2016 135978 -9% 106978 2% 42343 3% 83497 -16% 22621 4%
2017 147570 9% 107849 1% 40546 -4% 77930 -7% 25308 12%
2018 161734 10% 109556 2% 43077 6% 76397 -2% 24770 -2%
2019 193376 20% 115380 5% 48244 12% 77548 2% 22688 -8%
2020 128823 -33% 77294 -33% 34338 -29% 44632 -42% 13703 -40%
2021 161790 26% 86163 11% 45616 33% 52777 18% 13728 0%
Total 1078291 708501 295439 512679   144613  

 

Table 3B: Age Group wise analysis of Thyroid Stimulating Hormone results in five metro cities

TSH Mumbai Delhi Kolkata Bangalore Chennai
Age Group Normal Abnormal Normal Abnormal Normal Abnormal Normal Abnormal Normal Abnormal
0-15 26102 3968 30441 6501 8560 1621 22147 1784 14175 580
16-30 175672 45583 114022 31394 45197 13177 95733 26627 38280 7014
31-45 291161 91400 171469 58249 68497 23705 136774 44855 36021 8814
46-60 201361 69884 120541 43525 53348 20359 70782 27337 20050 5316
61-85 123468 46340 92386 35953 42012 17630 59890 25125 11219 2729
85+ 2280 1072 2763 1257 863 470 1086 539 301 114
Total 820044 258247 531622 176879 218477 76962 386412 126267 120046 24567

 

TSH Mumbai Delhi Kolkata Bangalore Chennai
Age Group Normal Abnormal Normal Abnormal Normal Abnormal Normal Abnormal Normal Abnormal
0-15 87% 13% 82% 18% 84% 16% 93% 7% 96% 4%
16-30 79% 21% 78% 22% 77% 23% 78% 22% 85% 15%
31-45 76% 24% 75% 25% 74% 26% 75% 25% 80% 20%
46-60 74% 26% 73% 27% 72% 28% 72% 28% 79% 21%
61-85 73% 27% 72% 28% 70% 30% 70% 30% 80% 20%
85+ 68% 32% 69% 31% 65% 35% 67% 33% 73% 27%

 

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CALCIUM TEST

A calcium test is included as part of routine wellness testing. Thyroid disorders, kidney disorders, malnutrition, malabsorption, vitamin D deficiencies or excess vitamin D intake are all related to calcium levels and hence is ordered both during diagnosis and treatment monitoring of these conditions.

  • In an analysis of Total Calcium Test results in five cities, we found that over 21% of women who underwent the calcium test reported abnormal levels.
  • In 2020, the first year of pandemic, Total Calcium tests dropped by over 32% as access to testing was restricted due to lockdown and fear of visiting a health care centre for health needs. In 2021, despite an increase in tests, the volumes did not reach pre-pandemic levels.


Table 4: Analysis of Calcium results in five cities

City Normal Abnormal Total Normal Abnormal
Mumbai 185413 33377 218790 84.74 15.26
Delhi 122862 43734 166596 73.75 26.25
Kolkata 34967 12176 47143 74.17 25.83
Bangalore 57062 18000 75062 76.02 23.98
Chennai 12141 5785 17926 67.73 32.27
Average 412445 113072 525517 78.48 21.52

 

Table 4A: Covid-19 Impact on routine tests for women – Calcium test

Year Mumbai % Delhi % Kolkata % Bangalore % Chennai %
2015 2512 21024 5684 14465 2512
2016 2450 -2% 22756 8% 6614 16% 9120 -37% 2450 -2%
2017 2892 18% 25202 11% 6481 -2% 10988 20% 2892 18%
2018 2605 -10% 26304 4% 7819 21% 10791 -2% 2605 -10%
2019 2906 12% 28477 8% 8143 4% 12301 14% 2906 12%
2020 2033 -30% 21078 -26% 5273 -35% 7493 -39% 2033 -30%
2021 2528 24% 21755 3% 7129 35% 9904 32% 2528 24%
Total 17926 166596 47143 75062 17926  

 

Table 4B: Covid-19 Impact on routine tests for women – Calcium test

Calcium Mumbai Delhi Kolkata Bangalore Chennai
Age Group Normal Abnormal Normal Abnormal Normal Abnormal Normal Abnormal Normal Abnormal
0-15 3595 642 6760 2551 1219 355 2057 614 600 305
16-30 25065 4253 15608 4380 3497 925 10449 2310 1547 1162
31-45 55234 10705 30602 9089 7977 2184 16336 4053 2664 1163
46-60 58157 8896 36032 10984 11793 3535 14222 4396 3532 1110
61-85 42571 8624 32642 15860 10228 5024 13694 6370 3571 1910
85+ 791 257 1218 870 253 153 304 257 227 135
Total 185413 33377 122862 43734 34967 12176 57062 18000 12141 5785

 

Calcium Mumbai Delhi Kolkata Bangalore Chennai
Age Group Normal Abnormal Normal Abnormal Normal Abnormal Normal Abnormal Normal Abnormal
0-15 85% 15% 73% 27% 77% 23% 77% 23% 66% 34%
16-30 85% 15% 78% 22% 79% 21% 82% 18% 57% 43%
31-45 84% 16% 77% 23% 79% 21% 80% 20% 70% 30%
46-60 87% 13% 77% 23% 77% 23% 76% 24% 76% 24%
61-85 83% 17% 67% 33% 67% 33% 68% 32% 65% 35%
85+ 75% 25% 58% 42% 62% 38% 54% 46% 63% 37%

VITAMIN D TEST

Vitamin D is considered the most underdiagnosed and undertreated nutritional deficiency across the world. Vitamin D deficiency is seen both in countries that are sunshine deficient and sufficient.

 

  • In an analysis of Vitamin D Test results in five cities, we found that over 72% of women who underwent the Vitamin D test reported abnormal levels.
  • In 2020, the first year of pandemic, Total Vitamin D tests dropped by over 41% as access to testing was restricted due to lockdown and fear of visiting a health care centre for health needs. In 2021, despite an increase in tests, the volumes did not reach pre-pandemic levels.

 

Table 5: Analysis of Vitamin D results in five cities

City Normal Abnormal Total Normal Abnormal
Mumbai 68169 182040 250209 27.24 72.76
Delhi 52456 129745 182201 28.79 71.21
Kolkata 12504 36733 49237 25.40 74.60
Bangalore 12691 47658 60349 21.03 78.97
Chennai 9665 14980 24645 39.22 60.78
Average 155485 411156 566641 27.44 72.56

 

Table 5A: Covid-19 Impact on routine tests for women – Vitamin D

Year Mumbai % Delhi % Kolkata % Bangalore % Chennai %
2015 30552 23650 5778 7095 2939
2016 31394 3% 29932 27% 6138 6% 7225 2% 3553 21%
2017 33718 7% 28600 -4% 6076 -1% 7537 4% 3015 -15%
2018 41798 24% 34106 19% 7606 25% 9264 23% 2537 -16%
2019 45456 9% 26773 -22% 9357 23% 11859 28% 2850 12%
2020 27916 -39% 18094 -32% 5802 -38% 7032 -41% 1340 -53%
2021 39375 41% 21046 16% 8480 46% 10337 47% 8411 528%
Total 250209 182201 49237 60349 24645  

 

Table 5B: Age Group wise analysis of Vitamin D results in five metro cities

Vitamin D Mumbai Delhi Kolkata Bangalore Chennai
Age Group Normal Abnormal Normal Abnormal Normal Abnormal Normal Abnormal Normal Abnormal
0-15 1841 4876 6653 19235 542 1267 403 1274 274 556
16-30 7052 31823 5057 24251 1305 5271 1659 10420 402 3680
31-45 18275 64926 11304 37166 2751 10797 4097 18067 810 5072
46-60 22437 49367 15146 30300 3967 11143 3243 10175 3893 3589
61-85 18156 30466 13883 18331 3831 8087 3212 7606 4044 2027
85+ 408 582 413 462 108 168 77 116 242 56
Total 68169 182040 52456 129745 12504 36733 12691 47658 9665 14980

 

Vitamin D Mumbai Delhi Kolkata Bangalore Chennai
Age Group Normal Abnormal Normal Abnormal Normal Abnormal Normal Abnormal Normal Abnormal
0-15 27% 73% 26% 74% 30% 70% 24% 76% 33% 67%
16-30 18% 82% 17% 83% 20% 80% 14% 86% 10% 90%
31-45 22% 78% 23% 77% 20% 80% 18% 82% 14% 86%
46-60 31% 69% 33% 67% 26% 74% 24% 76% 52% 48%
61-85 37% 63% 43% 57% 32% 68% 30% 70% 67% 33%
85+ 41% 59% 47% 53% 39% 61% 40% 60% 81% 19%

 

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FASTING BLOOD SUGAR TEST

The fasting blood sugar test measures the amount of blood sugar after 12 hours of overnight fasting. Fasting blood sugar test provides more accurate results and is easy to interpret. India is home to over 77 million diabetics and has the second-highest number of diabetes patients aged between 20-79 years as of 2019. Socioeconomic and demographic changes, along with increased susceptibility for diabetes in India individuals owing to genetic factors have led to an explosive rise in the prevalence of diabetes mellitus in India over the past forty years. In addition, the country also has a burden of ‘’pre-diabetes’’. Timely diagnosis can prevent pre-diabetes manifesting in to diabetes. Good sugar control in diabetics can also help prevent diabetes related complications.

  • In an analysis of Fasting Blood sugar results in five cities, we found that over 48% of women who underwent the fasting blood sugar test reported abnormal levels.
  • In 2020, the first year of pandemic, Fasting Blood Sugar tests dropped by over 33% as access to testing was restricted due to lockdown and fear of visiting a health care centre for health needs. In 2021, despite an increase in tests, the volumes did not reach pre-pandemic levels.

Table 6: Analysis of Fasting Blood Sugar results in five cities

City Normal Abnormal Total Normal Abnormal
Mumbai 249194 275132 524326 47.53 52.47
Delhi 152947 115781 268728 56.92 43.08
Kolkata 63435 89227 152662 41.55 58.45
Bangalore 86713 70972 157685 54.99 45.01
Chennai 29073 24672 53745 54.09 45.91
Average 581362 575784 1157146 51.02 48.98

 

Table 6A: Covid-19 Impact on routine tests for women – Fasting Blood Sugar

Year Mumbai % Delhi % Kolkata % Bangalore % Chennai %
2015 65464 36991 18137 26545 9246
2016 70118 7% 41426 12% 19441 7% 23622 -11% 7588 -18%
2017 74923 7% 42279 2% 20598 6% 25085 6% 8397 11%
2018 84650 13% 45239 7% 23203 13% 24223 -3% 8044 -4%
2019 90167 7% 40272 -11% 25473 10% 24478 1% 8397 4%
2020 57085 -37% 28784 -29% 19467 -24% 15485 -37% 5267 -37%
2021 81919 44% 33737 17% 26343 35% 18247 18% 6806 29%
Total 524326 268728 152662 157685   53745  

 

Table 6B: Age Group wise analysis of Fasting Blood Sugar results in five metro cities

RBS Mumbai Delhi Kolkata Bangalore Chennai
Age Group Normal Abnormal Normal Abnormal Normal Abnormal Normal Abnormal Normal Abnormal
0-15 3291 572 14003 2081 886 277 495 185 254 77
16-30 62177 12634 40367 8322 15904 4422 28635 5139 12800 2746
31-45 88728 54045 50716 24937 20529 18368 32266 15035 9300 5987
46-60 55632 105159 29048 43056 14138 34458 13953 25823 4473 8669
61-85 38441 101206 18317 36611 11691 31137 11110 24409 2185 7049
85+ 925 1516 496 774 287 565 254 381 61 144
Total 249194 275132 152947 115781 63435 89227 86713 70972 29073 24672

 

RBS Mumbai Delhi Kolkata Bangalore Chennai
Age Group Normal Abnormal Normal Abnormal Normal Abnormal Normal Abnormal Normal Abnormal
0-15 85% 15% 87% 13% 76% 24% 73% 27% 77% 23%
16-30 83% 17% 83% 17% 78% 22% 85% 15% 82% 18%
31-45 62% 38% 67% 33% 53% 47% 68% 32% 61% 39%
46-60 35% 65% 40% 60% 29% 71% 35% 65% 34% 66%
61-85 28% 72% 33% 67% 27% 73% 31% 69% 24% 76%
85+ 38% 62% 39% 61% 34% 66% 40% 60% 30% 70%

 

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TOTAL CHOLESTEROL TEST

Cholesterol is a waxy substance that is found in all the cells of the body and performs important function. It is important to keep the total cholesterol levels within the optimal levels. Higher levels of cholesterol is associated with and increased risk of heart disease. High cholesterol in itself does not cause any symptoms at all. It is important to routinely check for cholesterol levels. Only a blood test can reveal the levels of cholesterol in the blood.

  • In an analysis of Total Cholesterol Test results in five cities, we found that over 27% of women who underwent the total cholesterol test reported abnormal levels.
  • In 2020, the first year of pandemic, Total Cholesterol tests dropped by over 40% as access to testing was restricted due to lockdown and fear of visiting a health care centre for health needs. In 2021, despite an increase in tests, the volumes did not reach pre-pandemic levels.

Table 7: Analysis of Total Cholesterol results in five cities

City Normal Abnormal Total Normal Abnormal
Mumbai 280430 114709 395139 70.97 29.03
Delhi 172662 58911 231573 74.56 25.44
Kolkata 68511 22873 91384 74.97 25.03
Bangalore 128891 43291 172182 74.86 25.14
Chennai 38846 15077 53923 72.04 27.96
Average 689340 254861 944201 73.01 26.99


Table 7A: Covid-19 Impact on routine tests for women – Total Cholesterol Test

Year Mumbai % Delhi % Kolkata % Bangalore % Chennai %
2015 56015 24266 12109 34552 10351
2016 55930 0% 38862 60% 13239 9% 27986 -19% 9553 -8%
2017 59452 6% 38999 0% 14363 8% 27330 -2% 9549 0%
2018 62625 5% 41903 7% 15320 7% 24586 -10% 8490 -11%
2019 67694 8% 36065 -14% 14473 -6% 25959 6% 7300 -14%
2020 39010 -42% 22359 -38% 9223 -36% 13696 -47% 4314 -41%
2021 54413 39% 29119 30% 12657 37% 18073 32% 4366 1%
Total 395139 231573 91384 172182 53923  


Table 7B: Age Group wise analysis of Total Cholesterol Test results in five metro cities

 

Cholesterol Mumbai Delhi Kolkata Bangalore Chennai
Age Group Normal Abnormal Normal Abnormal Normal Abnormal Normal Abnormal Normal Abnormal
0-15 2566 537 15132 837 577 107 804 115 900 90
16-30 48989 7411 25485 3586 8796 1533 33767 5011 8668 1298
31-45 87450 31544 43825 14849 18755 6074 40401 12050 11476 4062
46-60 78988 48436 48291 25411 22846 9908 29070 16338 9919 6353
61-85 61376 26422 39141 13995 17282 5175 24487 9692 7583 3206
85+ 1061 359 788 233 255 76 362 85 300 68
Total 280430 114709 172662 58911 68511 22873 128891 43291 38846 15077

 

Cholesterol Mumbai Delhi Kolkata Bangalore Chennai
Age Group Normal Abnormal Normal Abnormal Normal Abnormal Normal Abnormal Normal Abnormal
0-15 83% 17% 95% 5% 84% 16% 87% 13% 91% 9%
16-30 87% 13% 88% 12% 85% 15% 87% 13% 87% 13%
31-45 73% 27% 75% 25% 76% 24% 77% 23% 74% 26%
46-60 62% 38% 66% 34% 70% 30% 64% 36% 61% 39%
61-85 70% 30% 74% 26% 77% 23% 72% 28% 70% 30%
85+ 75% 25% 77% 23% 77% 23% 81% 19% 82% 18%

 

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CREATININE TEST

The creatinine test measures the level of creatinine in the blood. Creatinine is a by-product from energy-production processes in muscles. Creatinine as a waste product exits through the urine. Kidneys filter creatinine out of the blood thus creatinine blood level measures how well the kidney is functioning. Elevated creatinine level signifies impaired kidney function or kidney disease. As the kidneys become impaired for any reason, the creatinine level in the blood will rise due to poor clearance of creatinine by the kidneys. Abnormally high levels of creatinine thus warn of possible malfunction or failure of the kidneys.

  • In 2020, the first year of pandemic, creatinine tests dropped by over 31% as access to testing was restricted due to lockdown and fear of visiting a health care centre for health needs. In 2021, despite an increase in tests, the volumes did not reach pre-pandemic levels.

 Table 8: Covid-19 Impact on routine tests for women – Creatinine

Year Mumbai % Delhi % Kolkata % Bangalore % Chennai %
2015 163264 181061 61937 149166 30032
2016 179432 10% 215406 19% 67225 9% 121050 -19% 31672 5%
2017 196859 10% 225445 5% 71065 6% 128626 6% 32502 3%
2018 204321 4% 242509 8% 81488 15% 128625 0% 30622 -6%
2019 236024 16% 242818 0% 89177 9% 140732 9% 29735 -3%
2020 164849 -30% 181917 -25% 61403 -31% 97718 -31% 18086 -39%
2021 217695 32% 214760 18% 74419 21% 115823 19% 18166 0%
Total 1362444   1503916   506714   881740   190815  

Creatinine tests dropped by over 31% in 2020, the first year of the pandemic. Despite an increase in volumes in 2021, testing volumes did not reach pre pandemic levels.

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Disclaimer: As an advanced Clinical Reference Laboratory, SRL receives samples for screening, diagnostic and monitoring purpose. Hence it is expected that there may be a bias in the statistical analysis of tests. Though we have endeavoured to remove repeat patient IDs for the data analysis, it is possible that some of the test results may be from repeat patients in this analysis that spans five years. The reason is that sometimes the patient is registered again under different coordinates as they fail to provide their unique patient ID.