In a published South African Medical Journal article, authors Marc Mendelson and Shabir Madhi highlighted flaws in South Africa’s current Covid-19 testing strategy and suggested some improvements.
The authors say that the country is now in an exponential phase where the focus needs to be shifted to reducing serious illnesses and deaths instead of trying to curb the spread. This, they suggest, can be done through the testing strategy.
Mendelson and Madhi describes the reverse transcriptase-polymerase chain reaction (RT-PCR) test used to diagnose Covid-19, as one that requires a lot of work. The turnaround time (TAT) of the test is dependent on how quickly samples are taken to laboratories, how many samples the lab is able to test and how the results can be conveyed.
Initially, the National Health Laboratory Service (NHLS) said that they would be able to test 36 000 samples per day, with a TAT of 12-24 hours. In the Western Cape, dubbed the “epicentre of the virus”, the TAT is currently 5 to 14 days. The article reports that the lab in Green Point, which is able to test 1000 samples per day, had 10 000 samples that were still not tested as of 7 May 2020.
The article further critiques the community screening and testing (CST) programme. The authors say that this programme cannot be sustained in the long-run because it does not provide much help if it is not conducted regularly. It is reported that each of the 28 000 field workers would need to screen more than 500 households, however, they are currently only reaching about 30 households each. According to Mendelson and Madhi, this approach will not be helpful in the event of further waves of infections over the next few years.
Trying to curb community transmission is currently unrealistic according to the authors, as the tracing of 80% close contacts of each person is not possible since 5200 people would need to be tracked if there are 400 new cases reported daily. The authors suggest that many of the new cases reported were most likely backlog from the previous week.
Mendelson and Madhi say that the public needs to be encouraged to implement the measures they can perform themselves.
“The focus should rather be getting public buy-in to adopting the non-pharmaceutical interventions of maintaining physical distancing, avoiding ‘mass gatherings’, meticulous performance of hand hygiene, wearing of cloth masks and good cough etiquette by everyone to reduce the risk of transmitting contaminated droplets, and decontaminating regularly used surfaces.”
With regards to hospitals, the authors suggest that patients be divided into ‘person under investigation’ (PUI) wards and non-PUI wards. Patients who are suspected to have Covid-19 would be placed in the PUI ward and should their tests return as positive, they should be placed in a ward solely for Covid-19 or in the intensive care units (ICU). Should the tests be negative, they will be cared for in wards or units away from patients who tested positive. By diagnosing and treating patients quickly, the authors say that our limited hospital facilities will not be overwhelmed.
Mendelson and Madhi suggest the following immediate measures:
- Halt testing in high-prevalence areas because community tracing will be too challenging and they will not be able to contain transmission.
- Instead, community health workers should continue screening and provide management guidelines to people in the most vulnerable districts and not send them for testing.
- An app should be available for people to report symptoms themselves. The authors say this will make it possible to monitor the spread and allow people displaying symptoms to self-isolate.
- Testing resources should be used on people where a faster TAT would greatly assist in bringing significant change. These groups include patients who have been hospitalised following a suspected severe case of Covid-19, Healthcare workers who are displaying symptoms and those who they come into close contact with and high-risk groups such as patients and staff at long-term care facilities.
- An intersectoral government task force should be established so that the stumbling blocks of the testing system can be dealt with and new recommendations can be made.
The journal article was originally published on 12 May 2020 and was authored by:
- Marc Mendelson: Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, South Africa
- Shabir Madhi: Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa;and Department of Science and Technology/ National Research Foundation, Vaccine-Preventable Diseases Research Chair, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa