key: cord-0902433-cn9ukws9
authors: Seidu, Abdul-Aziz; Hagan, John Elvis; Ameyaw, Edward Kwabena; Ahinkorah, Bright Opoku; Schack, Thomas
title: The role of testing in infectious disease control: A case of COVID-19 in Africa
date: 2020-06-30
journal: Int J Infect Dis
DOI: 10.1016/j.ijid.2020.06.089
sha: 44b746b8a0fdd6ad7d546754e8c12daf881dc441
doc_id: 902433
cord_uid: cn9ukws9

Abstract The dramatic increase in COVID-19 suspected cases in Africa has placed enormous burden on public and private clinical facilities. Till date, the most commonly used method for the identification and confirmation of the virus is the laboratory-based reverse transcription-polymerase chain reaction (RT-PCR) testing. Unfortunately, testing capacities have been limited in many parts of Africa because of inadequate test kits which have restricted scaling up beyond the few public health laboratories at designated locations. We present in this mini-review Africa’s preparedness and readiness toward testing, why testing is crucial, the need to immediately strengthen existing facilities and what it involves as combined approaches for managing the COVID-19 crisis. The review highlights the urgent need for speedy expansion and distribution of several laboratory testing platforms to public health facilities and fully accredited private clinical laboratories, including real-time PCR and serological assays.

As the COVID-19 situation exacerbates across the globe, Africa has had its fair share of the virus outbreak. Since February 14, 2020, when the first case was confirmed in the continent (in Egypt), all the 54 countries in Africa had confirmed cases as of 13 th May 2020 with Lesotho being the latest country to record the virus (African News 2020). As of 18 th June 2020, Africa had recorded a total of 267,818 cases with 7,219 deaths and 123,054 recoveries (Africa CDC, June 16, 2020) . Significant prevalence variation exists across countries across the continent. This ranges from four (4) cases in Lesotho to 80,412 cases in South Africa (Shaban, 2020) .

With the current outbreak characteristics per country, public health concerns could be critical if needed steps are not taken. Between and within country statistics show sporadic and faster COVID-19 community transmission and, countries may experience this scenario at the sub-national level (WHO, 2020) . Available data show that the Severe Acute Respiratory Syndrome Coronavirus 2 (SARSCoV-2) or COVID 19 is gradually spreading across the African population (Salathé et al., 2020) . Amidst this, some infected people may be unnoticed because of testing related challenges, including persons with COVID-19 compatible clinical disease(s) (Salathé et al., 2020) . WHO strongly encourages countries to prepare even before recording the first case (WHO, 2019). The preparation includes diverse individual protocols such as regular hand wash with soap and water, or cleaning them with alcohol-based hand rub and social J o u r n a l P r e -p r o o f distancing (i.e., maintaining at least 1 metre distance between persons). Similarly, covering one's mouth and nose when coughing or sneezing as well as avoidance of face touching constitute some of the individual protocols (WHO, 2019).

Other protocols include staying at home if one feels unwell, refraining from smoking and all activities that weaken the lungs, avoiding unnecessary travel as well as staying away from the crowd (WHO, 2020a). Apart from these individual measures, one step towards identification and treatment of the virus is testing for cases. WHO considers diagnostic testing for COVID-19 as critical. It is essential for tracking the virus and understanding its epidemiology in order to inform case management and transmission suppression (WHO, 2020b) . Therefore, in this minireview, explanations on Africa's preparedness and readiness, why testing is crucial in Africa, the need and how to immediately strengthen existing facilities to manage the COVID-19 crisis are provided.

At present, testing related competencies are restricted in many parts of Africa due to limited test kits that have prevented scaling up of testing beyond a few public health laboratories. To a large extent, it is evident from various country reports that the increasing number of suspected cases far outweighs the capacity of most health facilities in Africa, leaving many individuals untested (The New Humanitarian, 2020; Wild, 2020) . According to del Rio and Malani (2020), developing vigorous testing capacities is an unmet need in dealing with the current outbreak and crucial for discovering persons with the virus as well as those asymptomatic. Therefore, Africa's preparedness and readiness must focus on the establishment of SARSCoV-2 testing capacity in each country. Countries with minimal testing capacity should be readily prepared to refer J o u r n a l P r e -p r o o f samples of suspected cases to a WHO reference laboratory for COVID-19 testing through interlaboratory collaborations. Countries with local testing capacity at the national level should scaleup by decentralizing testing capacity through identified regional laboratories under strict supervision of the COVID-19 national reference laboratory. Additionally, testing facilities can be sited 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 (Salathé et al., 2020) . For instance, private laboratory services and/ or academic institutions with standardized laboratories could be additional options worth exploring, especially across other geographical locations in each country where difficulty in testing exist due to limited facilities (WHO, 2020). Although testing alone will not prevent the spread of COVID-19, it is part of other mitigation strategies to keep the current spread of the virus under control by preventing local transmission. This method should be readily available and the setbacks to it should be minimal as practicable (Salathé et al., 2020) .

Africa requires intense upscale of its testing capacities because of its limited capabilities in terms of test centres and existing diagnostic facilities with inadequate personnel and reagents. This is because providing laboratory testing for COVID-19 in suspected cases has clear benefits:

1. Testing for COVID-19 would let infected persons be aware of their status (i.e., positive status). People who do not know their status may ignore essential preventive and management protocols (e.g., social distancing, self-isolation) and thus put others at risk of infection (Roser et al., 2020) . For example, a COVID-19 case starts with minor symptoms that averagely manifests between 8-10 days after onset. Hence, testing will J o u r n a l P r e -p r o o f subsequently help discover other cohorts, contact trace and ensure preventive selfisolation of contacts. To African governments, this identification will facilitate follow-up measures to reduce the probability of infecting others. More extensive testing will provide more precise estimation of case fatality ratio related to the time between disease onset and possible deaths in foreseeable future (Salathé et al., 2020). Disappointingly, many countries in Africa do not have adequate capacity for COVID-19 testing (see Figure 1 ). Consequently, this could be one area that can seriously undermine the control of the possible spread of the virus on the continent (Agaba, 2020) . These procedures might be subject to modifications and special considerations depending on disease-specific characteristics (e.g., mode of transmission [blood-borne versus airborne] or recommended testing approach [molecular versus serology]) (Binnicker, 2020) .

Because of the inherent continental testing challenges of the current pandemic, there has been a rapid regional response to the pandemic across Africa. The Africa Centres for Disease

Task Force for Novel Coronavirus that recently launched the "Partnership to Accelerate COVID-19 Testing (PACT): Test, Trace, Treat in Africa" on 4 th June, 2020 (Africa CDC, June 16, 2020) .

PACT is to provide the needed assistance as joint continental strategy to help member states limit COVID-19 transmission. The Africa CDC recommends ensuring an uninterrupted supply of J o u r n a l P r e -p r o o f test kits, regents, and other essential supplies; pooling testing, reinforcing and expanding existing workforce by providing training to additional laboratory technicians to run tests; decentralizing testing to other qualified laboratories within countries; considering rapid diagnostics where this can be validated and standardized; automating streamlining, and ensuring uninterrupted laboratory processes; and ensuring a rapid and reliable specimen transport system (Africa CDC, 2020) . The Africa CDC further suggest that in order to identify cases and their contacts, there is the need to ensure smart screening in at-risk populations; sensitize and activate local detection points like patent medicine vendors, traditional healers and laboratories to identify cases; trace all case contacts; conduct active cases searching while investigating known cases; train and deploy community health workers to assist with contact tracing, community engagement and education, facilitate and encourage care-seeking for symptomatic individuals; and engage and empower community members to self-report and seek care (Africa CDC, 2020) . For treating symptomatic cases, the Africa CDC reiterates that providing guidance on home-based care to individuals experiencing mild symptoms; implementing infection prevention and control practices; immediate triage and testing of symptomatic individuals at healthcare facilities; ensuring the availability of critical equipment and their functionality (e.g. oxygen and oxygendelivering interfaces); and early identification and evidence informed management of individuals with moderate to critical illness as well as persons who are medically vulnerable (e.g. older patients, individual with comorbidities) are essential (Africa CDC, 2020) .

Based on these recommendations, up to one million test kits have been distributed across the continent. Similarly, 625,000 Polymerase Chain Reaction (PCR) tests have been given to 51 member countries and an extra support of 6,600 GeneXpert cartridges have also been supplied to three member states (i.e., Comoros, Guinea, Sao Tome) that have limited or no capacity for PCR J o u r n a l P r e -p r o o f testing. Other pathogen genomics equipment and reagents have also been supplied to member countries except Egypt (Africa CDC, June 16, 2020 (Wang et al., 2020) . Hence, the accuracy of data from the clinical testing will have a huge impact on the other follow-up protocols against the management and prevention of the virus spread (Stanfill, Giannangelo, & Fenton, 2020) . Therefore, the speedy expansion and distribution of several laboratory testing platforms by public health facilities and J o u r n a l P r e -p r o o f fully accredited private clinical laboratories, including real-time PCR and serological assays would be critical toward the response to the pandemic (Sharfstein et al, 2020) . Additionally, there should be interim guidance on the use of serological tests for COVID-19 response, especially in countries with limited and/ or no testing capacity. According to WHO (2020), although these procedures are very important, prioritizing testing should not prevent other appropriate interventions (e.g., home isolation, quarantine) to further curb the spread of the virus.

Only then would COVID-19 expectations and needs be met at local levels on the continent.

The authors have no conflict of interest to declare.

Funding Source: Nothing to declare Ethical Approval: Ethical approval for this study was not required in accordance with the policy of our institutions since the work did not involve the use of human subjects or animal experiments.

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

AS,JEH,EKA & BOA conceived the study. AS, JEH, EKA, BOA, and TS wrote and drafted the manuscript. All authors read and approved the final version of the manuscript.

J o u r n a l P r e -p r o o f

Partnership to Accelerate COVID-19 Testing (PACT) in Africa

Experts call for accelerated testing in Africa as WHO predicts up to 190,000 COVID-19 deaths

Emergence of a novel coronavirus disease (covid-19) and the importance of diagnostic testing: Why partnership between clinical laboratories, public health agencies, and industry is essential to control the outbreak

COVID-19-new insights on a rapidly changing epidemic

2019 Novel coronavirus-important information for clinicians

Coronavirus Disease (COVID-19)-Statistics and Research

COVID-19 epidemic in Switzerland: on the importance of testing, contact tracing and isolation

Diagnostic testing for the novel coronavirus

Health Information Management Best Practices for Quality Health Data During the COVID-19 Global Pandemic

African countries struggle to find the coronavirus test kits they need

Combination of rt-qpcr testing and clinical features for diagnosis of COVID-19 facilitates management of SARS-COV-2 outbreak

African countries are struggling to access Covid-19 test reagents on the open market

Novel coronavirus (2019-ncov) technical guidance

Coronavirus disease (COVID-19) advice for the public

Laboratory testing strategy recommendations for COVID-19: interim guidance

Laboratory testing for coronavirus disease 2019 (COVID-19) in suspected human cases: Interim guidance

Coronavirus disease (COVID-2019) situation reports