key: cord-0784646-5izdpr4k authors: Dzinamarira, Tafadzwa; Mukwenha, Solomon; Eghtessadi, Rouzeh; Cuadros, Diego F; Mhlanga, Gibson; Musuka, Godfrey title: COVID-19 response in Zimbabwe: A Call for Urgent Scale-up of Testing to meet National Capacity date: 2020-08-31 journal: Clin Infect Dis DOI: 10.1093/cid/ciaa1301 sha: 72d35265c46d3aeb42d87233ab8455027b746355 doc_id: 784646 cord_uid: 5izdpr4k Control of the coronavirus disease 2019 (COVID-19) heavily relies on universal access to testing to identify who is infected; tracking them to make sure they do not spread the disease further; and tracing those with whom they have been in contact. The recent surge in COVID-19 cases in Zimbabwe is an urgent national public health concern and requires coordinated efforts to scale up testing using capacity already in existence in country. There is need for substantial decentralization of testing, investment in better working conditions for frontline health workers and implementation of measures to curb corruption within government structures Various mitigation strategies have been put in place, including a three week Phase 4 (total) lockdown from end March to mid-April. Following the phase 4 lockdown; the country entered phase 2 lockdown with relaxed restrictions. This resulted in accelerated transmission, as prevention behaviour slackened (4) . In response, on 23 July, the government increased lockdown restrictions; including introduction of a dusk-to-dawn curfew. Further mitigation strategies include strides to increase testing capacity, training health workers on COVID-19 A c c e p t e d M a n u s c r i p t 5 patient care, and increase in the number of quarantine and isolation centers through authorization of some private facilities (4). Testing is an important strategy to contain or slow the progression of the pandemic in society (5) . The early detection of SARS-CoV-2 in infected people is important for limiting the transmission through isolation of cases, contact tracing and quarantine of contacts (1). Currently in Zimbabwe, testing is supposed to be done on suspect cases as per World Health Organization (WHO) case definition, contacts of confirmed cases and also patients identified through respiratory disease surveillance (4). However, testing has been prioritized for people with risk of developing severe disease, symptomatic health workers and the first symptomatic individuals in a new area or new cluster where no cases have been reported previously (4) . There is an urgent need to scale-up COVID-19 testing to meet current capacity and to ensure equal and equitable testing availability to all who want and/or need it. Fear of stigma and discrimination and labeling is deterring many from seeking testing (6, 7) . This is coupled with a fear of the unknown and hesitance of coping with isolation, should one test positive (8) . In the context of this novel virus, the content of COVID-19 information education communication (IEC) material is also rapidly evolving as clinical symptoms of the disease and the various mitigatory and containment measures are updated. IEC on benefits of testing (9) and associated counseling is minimal. Precise analysis of COVID-19 in Africa, as a continent, continues to be hindered by limited testing and reporting of cases. The wide variance in testing capacity, commitment to testing, and reporting of COVID-19 cases and deaths means countries that are undertaking the most tests or reporting the highest number of cases may not necessarily match those countries most A c c e p t e d M a n u s c r i p t 6 impacted or at risk from the pandemic (10). In Zimbabwe, the testing of SARS-CoV-2 virus has evolved over time. Trained medical laboratory scientists and technicians perform COVID-19 testing in Zimbabwe. Training on testing is provided by Ministry of Health and Child Care supported by various organisations such as the WHO, and Africa Centres for Disease Control and Prevention (Africa CDC), among others. The country follows the WHO guidelines on testing (11) . Initially confirmatory PCR testing was done at National Institute of Communicable Diseases in South Africa (4) . Over time, laboratory support for PCR tests was extended to five public laboratories in the country, that had existing platforms for HIV testing, and to date multiple other districts, provincial and private laboratories have been authorized to test for the SARS-CoV-2 virus. Provinces are showing marked differences in the COVID-19 testing levels, and although there is a high density of testing sites in the current COVID-19 hotspots like Harare an Bulawayo, the testing capacity of these provinces in relation to their population density is rather low (Figure 2 ), whereas Matabeleland North and South had the largest testing capacity in relation to their population density. Testing has been done in the form of rapid antibody testing and PCR testing. Rapid antibody testing has been used as a screening test at the borders and workplaces whereas PCR has been used as a diagnostic test for all symptomatic people, hospitalized patients, people who are positive with rapid antibody testing. As of 18 August 2020, a total of 84,741 PCR tests have been done (3) . The testing sites have employed various molecular platforms with the district and provincial laboratories mostly relying on GeneXpert (Cepheid) analysers. Table 1 presents the distribution of PCR platforms and assays with an account of the throughput assuming an 8-hour work shift. Combined, the laboratories have a capacity of 9,658 PCR tests daily. As at 18 August 2020, the country is conducting an average of 1,200 diagnostic PCR tests per day (3) . This available data for Zimbabwe shows inadequate testing levels that do not meet current capacity. The WHO issued a warning of a "silent epidemic" to African A c c e p t e d M a n u s c r i p t 7 governments, calling for testing to be prioritized, and delivered on a much greater scale than it is at the moment (12) . The next section discusses barriers to widespread COVID-19 testing in Zimbabwe focusing on procurement, health system funding, health workforce and standards at quarantine facilities. March with a peak at the end of April. This trend, has in part been due to persistent challenges with procurement and supply chain of COVID-19 test kits (13) . A shortage of reagents and consumables among them Gene Xpert cartridges, nasopharyngeal swabs, Viral Load Transport medium (VTM) and other reagents for PCR has hampered COVID-19 testing in Zimbabwe. This has severely impacted on the testing capacity leading to high turn-around of results thereby impacting service delivery. The global demand for the kits and reagents has seen manufacturing countries prioritize their homelands (14, 15 ). According to Médecins Sans Frontiers research, diagnostics company Cepheid is charging four times more than it should for its COVID-19 tests (16) . Cepheid has set the price for each test at $19.80 in 145 developing countries, including Zimbabwe, when the tests could be sold at a profit for $5 each (16) . Given the majority of testing sites in Zimbabwe rely on the Cepheid platform for COVID-19 testing (4), the cost per kit may also deter widespread testing for private facilities that purchase their own test kits. Further, it is worth noting that the closure of borders and grounding of most cargo ships and flights also had adverse impact on importing the kits to Zimbabwe. Corruption in procurement of COVID-19 reagents has also emerged, resulting in A c c e p t e d M a n u s c r i p t 8 some tenders being cancelled and thereby delaying the procurement process (17) . This also brings into disrepute the credibility of the government in handling donor funds, thus derailing or even stopping some donations which may have been earmarked for the country. Another important major barrier to widespread COVID-19 testing in Zimbabwe has been the chronically underfunded health system. The testing has relied on donors from Jack Ma, The United States Centres for Disease Control and Prevention and other partners (18) who have made substantial contribution to the effort to boost the COVID-19 testing in Zimbabwe. In the early phases of the pandemic, sample transportation was a major challenge (7), and consequently , MoHCC, in collaboration with its partners, have put in place a transport system that leverages on existing HIV program to ferry samples to the laboratories. However, in a country with severe shortages of fuel, the challenge of sample transport persists in some areas. Zimbabwe has also experienced a "brain drain" as more skilled medical laboratory scientists have continued to evade district and provincial hospitals, in favor of better working conditions in neighboring and overseas countries (19) . According to the Health Services Board, 64% of medical laboratory scientist positions in public laboratories were vacant as of December 2019 (20). This implies that even most laboratories may not meet their daily capacity because there aren't enough people there to prepare and process the samples. Further, this also negatively impacts the quality of testing in the public laboratories which A c c e p t e d M a n u s c r i p t 9 have been left to be manned by less skilled cadres. The government-employed nurses and doctors have been on strike due to low remuneration coupled with salaries that are continuously eroded by hyperinflation. A new threat has emerged with a surge in number of health workers testing positive for SARS-CoV-2 virus. As of 28 July, 323 health workers had tested positive for SARS-CoV-2 virus (21) . Subsequent isolation of the confirmed cases and quarantine of their colleagues who have been in close contact has reduced the number of health workers available to serve patients (22) . The health workers have also reported lack of personal protective equipment (PPE) which is essential in discharging their duties especially during this COVID-19 crisis (7, 23) . The strike, low morale and quarantine of the infected health workers are causing increased fatigue among the few health workers thereby compromising the quality of service. The country initially experienced a significant number of imported cases from neighboring South Africa through both designated and undesignated ports of entry (3). The undesignated port of entry has presented a major challenge as the people using these ports of entry are not documented and tested before they interact with other people in the society (24) . Even for those individuals who followed the right procedures for entry into the country, cases of individuals escaping from the quarantine centers have been reported (25). There is a growing body of evidence that call for quarantine centers to scale up provision of proper counselling, support and treatment to the returnees (8, 26) . When people are well-informed and knowledgeable about the merits of the whole process, they are more likely to comply. A joint A c c e p t e d M a n u s c r i p t 10 team comprised of MoHCC, the International Organization for Migration and WHO assessed the suitability and appropriateness of 37 quarantine facilities across the country during the period 17 -21 May 2020. The assessment revealed a lack of guidance of how the facilities should be operating (27) . In some facilities, roles and responsibilities were not clearly defined (27) . The occupants were not practicing maximum safety measures to avoid or limit transmission within the facilities (27) . There was no guidance on Infection Prevention and Control (IPC) issues at the facilities and PPEs were in short supply (27) . There is an urgent need to train quarantine staff on COVID-19, safety and maintenance of hygiene, regular screening and testing of quarantine staff, develop and distribute standard operating procedures (SOPs) and guidelines for IPC at the quarantine facility, procure and provide adequate supplies required for infection prevention and control (28) . Currently, COVID-19 diagnostic testing is mandatory at day 8 of quarantine (28) . There is need to consider COVID-19 testing upon arrival at the quarantine site. Recently, local cases have also been on the increase and beginning July the number have surpassed imported cases (3). This is an illustration that the pandemic has moved into a profile, which is localized, and therefore this has an implication on testing targets and patterns. Further, this trend underscores the need to continuously engage the community (29, 30) to adhere to various containment and mitigation strategies in place to reduce infections. A c c e p t e d M a n u s c r i p t 11 As the outbreak accelerates in the country, the call to ramp up COVID-19 testing to meet the current capacity to better control the pandemic cannot be over-emphasized. To rapidly improve testing capacity, there is need for provision of adequate resources (31) coupled with motivated health workers. Political will plays an important role in ensuring that testing capacity is increased, as decisions will be made at the highest level and implemented cascading downwards. In this regard, domestic rechanneling of resources from other line ministries, to health, will be crucial as external aid support is likely to diminish. Since the inception of the pandemic, the government has recruited additional health workers and introduced a COVID-19 allowance. While the government has made efforts to reshuffle staff around clinics to focus on the facilities with the most COVID-19 related workload, there is need for development of programs for periodic debriefing and burn-out prevention for frontline workers. Frontline health workers who are testers, also need psychosocial support, especially if they are witnessing increased positive rates of testing, or if they are witnessing highly distressed patients at the time of testing (32). Dealing with anxiety of frontline health workers is just as important as dealing with client anxieties. The government may also consider stepping up efforts to re-engage skilled health workers, who have moved to other sectors of work, to ease the strain on the core health care complement. Zimbabwe is a recipient of important financial support for the HIV pandemic, these resources can be leveraged in the COVID-19 response. The United States government (USG)'s substantial HIV-related investments in Zimbabwe have also focused on laboratory infrastructure (33, 34) . The USG has employed a two-pronged approach, namely provide support to national laboratory capacity focused on HIV Viral load testing, QA/QC programs through its laboratory focused implementation partners. Secondly, its HIV surveillance There is need to urgently address issues of graft that have been reported in procurement process (37) . In the context of the COVID-19 pandemic, Civil society organizations (CSOs) can play an important role in demanding enhanced transparency and good governance in Zimbabwe by contributing to increased public debate on issues surrounding the formulation and implementation of COVID-19 financial resources. CSOs and development partners need to adopt creative means to track, monitor and shadow report on disparities and anomalies which emerge in resource and commodity utilization, on a frequent basis. The Zimbabwean COVID-19 response could benefit from CSOs cooperation with national and international human rights agencies (38) and donors, to guide the effective tracking and shadow reporting. CSOs can also be engaged to support testing efforts in motivating and mobilizing communities to take up COVID-19 testing. There is need for sustainable scale-up to ensure community literacy is increased, and mobilize acceptance of testing (9) . IEC dissemination, preferably in vernacular languages, should be availed via radio, TV and digital social media platforms. In the context of quarantine of returnees, wide access to COVID-19 IEC dissemination is fundamental to A c c e p t e d M a n u s c r i p t 14 remove stigma against returnees that has potential to cause an underground divide with a likelihood of ultimately countering prevention efforts. Further, there is need for training for health workers to ensure proper pre-and post-test counseling is offered; to both persons being tested and their family to alleviate anxiety and deter self-stigma or external stigma and discrimination (39) . We recommend Zimbabwe to embrace pooled testing (40) for cohesive groups such as health care workers. This approach is particularly useful in these groups where a single positive typically requires quarantine of the entire group. Pooled testing has also been shown to be useful among asymptomatic and pre-symptomatic COVID-19 patients, an important source of transmission (40) . Zimbabwe's limited testing capacity has been mainly due to inadequate investment by its government, over the years, to the health system. The government must increase its own financial investment in the response to COVID-19 and not be solely dependent on international donors. 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