The role of testing in the fight against COVID-19

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Perspective

The role of testing in the ﬁ ght against COVID-19: Current happenings in Africa and the way forward

Abdul-Aziz Seidu

^a,b,

*, John Elvis Hagan Jr.

^c,e

, Edward Kwabena Ameyaw

^d

, Bright Opoku Ahinkorah

^d

, Thomas Schack

^e

aDepartmentofPopulationandHealth,UniversityofCapeCoast,CapeCoast,Ghana

bCollegeofPublicHealth,MedicalandVeterinarySciences,JamesCookUniversity,Townsville,Queensland,Australia

cDepartmentofHealth,PhysicalEducation,andRecreation,UniversityofCapeCoast,CapeCoast,Ghana

dTheAustralianCentreforPublicandPopulationHealthResearch[ACPPHR],FacultyofHealth,UniversityofTechnologySydney,Australia

eNeurocognitionandAction-Biomechanics-ResearchGroup,FacultyofPsychologyandSportSciences,BielefeldUniversity,Bielefeld,Germany

ARTICLE INFO

Articlehistory:

Received14April2020

Receivedinrevisedform23June2020 Accepted25June2020

Keywords:

RT-PCR Serological SARS-CoV-2 Laboratory Testkits Africa Assay

ABSTRACT

ThedramaticincreaseinsuspectedCOVID-19casesinAfricahasplacedanenormousburdenonpublic andprivateclinicalfacilities.Todate,themostcommonlyusedmethodforidentifyingandconﬁrming the virus is the laboratory-based reverse transcription-polymerase chain reaction (RT-PCR) test.

Unfortunately,testingcapacitieshavebeenlimitedinmanypartsofAfricabecauseofinadequatetest kits,whichhaverestrictedscalingupbeyondthefewpublichealthlaboratoriesatdesignatedlocations.

Inthismini-review,wepresentAfrica'spreparednessandreadinessfortesting,whytestingiscrucial,the needtoimmediatelystrengthenexistingfacilities,andwhatitinvolvesaspartofcombinedapproaches formanagingtheCOVID-19crisis.Thereviewhighlightstheurgentneedforspeedyexpansionand distributionofseverallaboratorytestingplatforms,includingreal-timePCRandserologicalassaysto bothpublichealthfacilitiesandfullyaccreditedprivateclinicallaboratories.

ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc- nd/4.0/).

Introduction

As the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-COV-2) or COVID-19 situation exacerbates worldwide, Africahashaditsshareofthevirusoutbreak.SinceFebruary14, 2020, when the first case was confirmed onthe continent (in Egypt),all54countriesinAfricahadconfirmedcasesasofMay13, 2020,withLesotho beingthelatestcountrytorecordthevirus (AfricanNews 2020). As of June 18, 2020, Africahad recorded 267,818cases,with7,219 deathsand 123,054recoveries(Africa CDC, June 16, 2020). Significant variation in prevalence exists acrossthecontinent,rangingfromfourcasesinLesothoto80,412 casesinSouthAfrica(Shaban,2020).

With the current outbreak characteristics in Africa, public health concerns couldbecome critical if needed stepsare not taken.Betweenandwithin-countrystatisticsshowsporadicand fasterCOVID-19communitytransmission;countriesmayexperi- ence this scenario at the sub-national level (WHO, 2020c).

AvailabledatashowthatCOVID-19isgraduallyspreadingacross theAfrican population(Salathéet al.,2020).Amidstthis, some infected people may be unnoticed because of testing-related challenges,includingpersonswithCOVID-19compatibleclinical disease(s) (Salathé et al., 2020). WHO strongly encourages countries to prepare even before recording their ﬁrst case (WHO,2019a,b).Preparationincludesdiverseindividualprotocols such as regular handwashing withsoap and water or with an alcohol-basedhandrubandsocialdistancing(i.e.,maintainingat least one meter distancebetween persons). Similarly, covering one'smouthandnosewhencoughingorsneezingandavoiding face self-touching constitute some of the individual protocols (WHO,2019a,b).Otherprotocolsincludestayingathomeifone feels unwell, refraining from smoking and all activities that weakenthelungs,avoidingunnecessarytravelandstayingaway fromcrowds(WHO,2020a).

* Correspondingauthorat:DepartmentofPopulationandHealth,Facultyof SocialSciences,CollegeofHumanitiesandLegalStudies,TheUniversityofCape Coast,PMBUniversityPrivateMailBag,CapeCoast,Ghana.

E-mailaddresses:[email protected](A.-A.Seidu), [email protected](J.E.Hagan),[email protected](E.K.Ameyaw), [email protected](B.O.Ahinkorah),[email protected] (T.Schack).

https://doi.org/10.1016/j.ijid.2020.06.089

1201-9712/©2020TheAuthor(s).PublishedbyElsevierLtdonbehalfofInternationalSocietyforInfectiousDiseases.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).

InternationalJournalofInfectiousDiseases98(2020)237–240

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Apart from these individual measures, one step towards identifyingand treatingpersonswiththevirusis testing.WHO considersdiagnostictestingforCOVID-19,critical.Itisessentialto trackthevirusand understanditsepidemiology toinform case managementandsuppresstransmission(WHO,2020b).Therefore, inthismini-review,weprovideadiscussionofAfrica'spreparednesstowardstesting,whytestingiscrucial,theneedforandhowto immediatelystrengthenexistingfacilitiestomanagetheCOVID-19 crisis.

Africa'spreparednesstowardstesting

Atpresent,testing-relatedcompetenciesarerestrictedinmany partsof Africadue toa limitednumber oftest kits,preventing scalingupoftestingbeyondafewpublichealthlaboratories.Itis evidentfromvariouscountryreportsthattheincreasingnumberof suspectedcasesfaroutweighsthecapacityofmosthealthfacilities inAfrica,leavingmanyindividualsuntested(TheNewHumani- tarian,2020;Wild,2020).AccordingtodelRioandMalani(2020), developingvigoroustestingcapacitiesisanunmetneedindealing withthecurrentoutbreak,crucialforverifyingpersonswiththe virus as well as discovering those who are asymptomatic.

Therefore, Africa's preparedness must focus on establishing COVID-19 testing capacities in each country. Countries with minimal testing capacity should be quickly equipped to refer samplesof suspected cases to a WHO reference laboratory for COVID-19 testing through inter-laboratory collaboration.Coun- trieswithtestingcapacityatthenationallevelshouldscale-upby decentralizingtestingcapacitythroughidentiﬁedregionallabora- tories under the strict supervision of the COVID-19 national referencelaboratory.Additionally,testingfacilitiescanbelocated outside of hospitals to avoid overburdening already minimal hospital resources and the potential risk of facility-based (i.e., nosocomial) transmission to other patients and healthcare personnel(Salathéetal., 2020).For instance,privatelaboratory servicesand/oracademicinstitutionswithstandardizedlaborato- ries couldbe additional options worth exploring, especially in geographical locationswhere difﬁcultyin testing existsdue to

limitedfacilities (WHO, 2020c).Althoughtestingalonewill not prevent the spread of COVID-19, it is part of the mitigation strategies to keep the virus's current spread under control by preventing local transmission. This method should be readily available,andsetbackstoitshouldbeasfewaspracticable(Salathé etal.,2020).

Whytestingiscrucial

Africa requires an intense uprading of its testing capacities because of its limited capabilities in test centers and existing diagnosticfacilitieswithbothinadequatepersonnelandreagents.

This is because providing laboratory testing for COVID-19 in suspectedcaseshasclearbeneﬁts.TestingforCOVID-19wouldlet infected persons be awareof their status (i.e., positive status).

People who do not know their status may ignore essential preventiveandmanagementprotocols(e.g.,socialdistancing,self- isolation)andthusputothersatriskofinfection(Roseretal.,2020 a). For example, a typical COVID-19 case starts with minor symptomsthatonaveragemanifestbetween8and10daysafter onset. Hence, testing will subsequently help to discover other cohorts,tocontacttrace,andtoensurepreventiveself-isolationof contacts.ForAfricangovernments,thisidentiﬁcationwillfacilitate follow-upmeasurestoreducetheprobabilityofinfectingothers.

Moreextensivetestingwillprovideamorepreciseestimateofthe case-fatalityratiorelatedtothetimebetweendiseaseonsetand possibledeath,intheforeseeablefuture(Salathéetal.,2020).

Throughtesting,properevidence-basedmeasuresagainstthe pandemiccanbeimplemented,basedonmoreaccurateinforma- tionaboutthenumberofcases.Suchanestimationwillfacilitate theallocationofCOVID-19relatedhospitalresources(e.g.,ICUbed, nose/face mask,and otherprotectiveequipment requirements).

Withoutcleardataontheepidemiologicalsituationontheground, frontline health workers will face problems in their quest to managethepandemic,inparticularidentifyingwhatpercentageof persons have mild, severe, and critical symptoms. The testing processwillhelpunderstandthespreadofthediseaseandthereby guide the implementation of appropriate interventions to

Figure1.TestsconductedpernewconﬁrmedcasesofCOVID-19inAfrica,June19,2020(Roseretal.,2020b).

238 A.-A.Seiduetal./InternationalJournalofInfectiousDiseases98(2020)237–240

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minimizetheinfection'sspread(Roseretal.,2020a;Salathéetal., 2020).BycontinuousmonitoringofCOVID-19testresults,aclear temporalpictureonwhethercontrolmeasureshavebeeneffective ornotwillbeestablished,thusprovidingneededinformationfor alternatemeasurestobeexplored,atany speciﬁctime (Salathé etal.,2020).Unfortunately,manycountriesinAfricadonothave adequate capacity for COVID-19 testing (see Figure 1). Conse- quently,thiscouldbeoneareathatcanseriouslyunderminethe control of thevirus's possible spread onthe continent (Agaba, 2020).

Bridgingthetestinggap

Drawing onthe lessons of Ebola, the 2009 H1N1 influenza pandemic,andSARS-CoV,itwillbecriticaltodevelopacountry- specific framework guided by standardized WHO guidelines in responsetoanemergingviraloutbreaklikeCOVID-19.Immediate involvement of technical knowhow and the directives from reputable institutions (e.g., Centre for Disease Control [CDC]), localgovernments,publichealth departments,clinicallaborato- ries,healthcareprovidersaswellasotherstakeholdersshouldbe onthe frontlineservices(Binnicker, 2020).Atthe onset of the outbreak,itisessentialthatlocalinstitutions(e.g.,CDC,Foodand DrugsAuthority[FDA])andWHO,speedilydevelopnewdiagnostic testsbasedontheirpreviousexperiencewithinfectiousdisease control. Testreagent manufacturerscould beidentified for the massproductionoftestreagentsafterdevelopinganassaythathas beenverified,basedonstandardperformancecharacteristics,by partneringpublichealthagencies.Afterauthorizingtheusageof test kits,immediatelocal distributionby testmanufacturers to qualifiedlaboratories(i.e.,stateandlocalpublichealthlaborato- ries) should be the next step. The decision to include private clinical laboratories should be made after a thoroughly vetted processthatcouldinclude:

1.registeringlocalclinicallaboratoriestomeetapprovedequip- ment,safetyset-up,andpersonneltofacilitatetestingrequire- ments,

2.afollow-upsite-visitbyanexpertfromanalreadyestablished CDC-qualiﬁedlaboratoryrepresentative,and

3.adouble-blindcertiﬁcationpaneldirectedbytheCDCand/or testmanufacturertotheclinicallaboratory.

Theseproceduresmightbesubjecttomodiﬁcationsorspecial considerationsdependingondisease-speciﬁccharacteristics(e.g., modeof transmission [blood-borne versusairborne] or recom- mended testing approach [molecular versus serological]) (Bin- nicker,2020).

Becauseofthecurrentpandemic'sinherentcontinentaltesting challenges, there has been a faster regional response to the pandemicacrossAfrica.TheAfricaCentresforDiseaseControland Prevention, in partnership with WHO's African Region, have introducedanAfricaTaskForceforNovelCoronavirusthatrecently launchedthe“PartnershiptoAccelerateCOVID-19Testing(PACT):

Test,Trace,TreatinAfrica”onJune4,2020(AfricaCDC,June16, 2020). PACT is to provide the needed assistance for a joint continental strategy to help member states limit COVID-19 transmission.TheAfricaCDCrecommends:

1.ensuring an uninterruptedsupply of test kits, reagents, and otheressentialsupplies,

2.poolingtesting,reinforcingandexpandingtheexistingwork- forcebyprovidingtrainingtoadditionallaboratorytechnicians toruntests,

3.decentralizing testing to other qualiﬁed laboratories within countries,

4. consideringrapiddiagnosticswherethiscanbevalidatedand standardized,

5. automatingstreamlining,andensuring uninterruptedlabora- toryprocesses,and

6. establishing a rapid and reliable specimen transport system (AfricaCDC,2020a).

TheAfricaCDCfurthersuggeststhattoidentifycasesandtheir contacts,thereistheneedto:

1. guaranteesmartscreeningofat-riskpopulations,

2. sensitize and activate local detection points like patent medicinevendors,traditionalhealers,andlaboratoriesinorder toidentifycases,

3. traceallcasecontacts,

4. conductactivecasessearchingwhileinvestigatingknowncases, 5. train and deploy community health workers to assist with

contacttracing,communityengagement,andeducation, 6. facilitateandencouragecare-seekingforsymptomaticindivid-

uals,and

7. engageandempowercommunitymemberstoself-reportand seekcare(AfricaCDC,2020a).

Fortreatingsymptomaticcases,theAfricaCDCreiteratesthat thesemeasuresareessential:

1. providing guidance on home-based care to individuals experiencingmildsymptoms,

2. implementinginfectionpreventionandcontrolpractices, 3. immediate triage and testing of symptomatic individuals at

healthcarefacilities,

4. guaranteeing the availability of critical equipment and their functionality (e.g., oxygen and oxygen-delivering interfaces), and

5. early identiﬁcation and evidence-informed management of individuals with moderate to critical illness and medically vulnerable persons (e.g., older patients, individuals with comorbidities)(AfricaCDC,2020a).

Basedontheserecommendations,uptoonemilliontestkits have been distributed across the continent. Similarly, 625,000 Polymerase Chain Reaction (PCR) tests have been given to 51 member countries, and the extra support of 6600 GeneXpert cartridgeshavealsobeensuppliedtothreemember states(i.e., Comoros,Guinea,SaoTome)thathavelimitedornocapacityfor PCR testing. Otherpathogengenomicsequipment and reagents have alsobeensupplied tomember countries except forEgypt (AfricaCDC,June16,2020).

Laboratorytestingcapacityhasincreasedfrom2to44African countries (https://apps.who.int/iris/bitstream/handle/10665/

331763/SITREP_COVID-19_WHOAFRO_20200415-eng.pdf). Con- siderableeffortsarenowongoingtoincreasediagnosticcapacity acrossthecontinent.Forinstance,thereare44hospitalswith32 specializedcentersthatareadequatelyresourced inresponseto the current outbreak in Morocco (https://www.moroccoworldnews.com/2020/03/296658/moroccoannounces-5-new-cases-of- covid-19-bringing-total-to-54/).Aswell,Algeria, Ghana,Nigeria, Senegal,SouthAfrica,andanumberofotherAfricancountrieshave establishedlaboratoriesforwithin-countrytestingofCOVID-19.

Conclusions

CountriesinAfricahaveintroduceddifferentstrategiestobattle COVID-2019.However,theseinterventionsarenotwithoutserious setbacks(e.g.,limitedorzerotestingcapacity,inadequatelytrained personnel). The World Health Organisation (WHO) and donor A.-A.Seiduetal./InternationalJournalofInfectiousDiseases98(2020)237–240 239

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institutions could collaborate with local governments in the Africanregiontocreatenewhealthinfrastructures(e.g.,referral laboratories) and expand existing ones with relevant health logistics. Successful diagnosis of COVID-19 depends on proven scientific observations,laboratory findings, and epidemiological connections(Wanget al.,2020).Hence,data accuracyfromthe clinicaltestingwillhaveaconsiderableimpactontheotherfollow- upprotocolstomanageandpreventthevirusspread(Stanfilletal., 2020).Therefore,aspeedyexpansionandgeographicaldistribu- tion of several laboratory testing platforms by public health facilitiesandfullyaccreditedprivateclinicallaboratories,including real-timePCRandserologicalassays,willbecriticalforaresponse tothepandemic(Sharfsteinetal.,2020).Additionally,thereshould beinterimguidanceontheuseofserologicaltestsforCOVID-19, especiallyincountrieswithlimitedand/ornotestingcapacity.

According to WHO (2020), although these procedures are fundamental, prioritizing testing should not impede other appropriate interventions(e.g., homeisolation and quarantine) tofurthercurbthevirus'sspread.OnlythenwouldAfrica'sCOVID- 19expectationsandneedsbemetatlocallevelsonthecontinent.

Funding

WesincerelythanktheGermanResearchFoundationthrough the Neurocognition and Action-Biomechanics Research Group, BielefeldUniversity,Germanyforprovidingﬁnancialsupportfor thepublicationofthisresearch.

Ethicalapproval

Ethical approval for this study was not required per our institutions’ policies,since thework didnot involve theuseof humansubjectsoranimalexperiments.

Conﬂictofinterest

Theauthorshavenoconﬂictofinteresttodeclare.

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