key: cord-0956708-rh0ym5qx authors: Giri, Anil K.; Rana, Divya R.S.B.B. title: Charting the challenges behind the testing of COVID-19 in developing countries: Nepal as a case study date: 2020-05-13 journal: nan DOI: 10.1016/j.bsheal.2020.05.002 sha: d340fbebab79226763c9522a91801f58f7671ad1 doc_id: 956708 cord_uid: rh0ym5qx Abstract The infrastructure needed to detect SARS-CoV-2 infection (COVID-19) that complies completely with WHO guidelines is lacking across many parts of the globe, especially in developing countries, including Nepal. We outline the problems faced by such countries and suggest that the national and international community should collaborate in the development and adoption of novel protocols for the rapid detection of COVID-19 according to locally available infrastructure, in order to fight against the outbreak. betacoronavirus SARS-CoV-2 and was detected for the first time in Wuhan, China [1] . The World Health Organization (WHO) has characterized COVID-19 as a pandemic [2] , and according to WHO Situation Report No. 97, about 2.8 million individuals globally have been confirmed to be infected and more than 190 thousands have died by 26 April, 2020 [3] . While most people with COVID-19 develop a mild illness, approximately 14% develop severe disease requiring hospitalization and 5% need intensive care unit support [4] . Inadequate health care facilities to provide treatment and life support to a potentially exponentially increasing number of patients due to an outbreak in a community, can in turn lead to more disease transmission from untreated cases. The WHO strongly recommends testing of suspects for COVID-19 and the individuals who have been in contact with them in order to control the infection in a community [5] . However, due to the high infectivity of the virus and lack of appropriate resources (e.g., testing laboratories, kits), most of the world is struggling to contain the spread of virus and is facing an increasing number of fatalities. Risk on mortality risk is much higher in developing countries with poor scientific and health infrastructure such as Nepal, and these countries are struggling to test for and track the infection due to a lack of laboratory facilities and trained manpower [6] . Lack of good laboratory practices and safety information, as well as social prejudices about the disease are other barriers in to the fight against the virus in the developing world. In this manuscript, we outline these problems and discuss strategies that can be adapted for the rapid detection of COVID-19 in developing countries. Swift collection and testing of biological samples from patients meeting the suspected case definition for COVID-19 are critical for proper monitoring and control of disease infection in the community. The WHO has recommended the testing of COVID-19 J o u r n a l P r e -p r o o f infection using a reverse transcription polymerase chain reaction (RT-PCR)-based protocol to target different viral genes [7] . However, these testing protocols require RNA extraction kits, costly RT (quantitative) -PCR machines and trained technicians to operate them. These resources are limited in countries with poor scientific infrastructure, such as Nepal, where there was only one laboratory equipped to test for coronavirus infection [8] , with an increase to three planned for the end of March 2020 [9] . The establishment of fully equipped testing laboratories that fulfil WHO guidelines would require huge investment, expertise and time, which are currently limited by the COVID-19 crisis. Alternative testing protocols that allows COVID-19 testing with limited resources and available manpower in the country, will be highly useful in the fight against the COVID-19 pandemic. We suggest that colorimetric loop-mediated isothermal amplification (LAMP) can serve as an alternative COVID-19 testing protocol in developing countries. This method requires a centrifuge (e.g. for RNA extraction, if needed) and a heating system (e.g. a water bath for RNA amplification) as the two major instruments, and these can be easily arranged, even in countries with limited scientific infrastructure [10] . LAMP is a novel nucleic acid amplification technique that amplifies DNA with high specificity, efficiency and rapidity under isothermal conditions (usually 65°C) [11] . Recently, multiple pre-print publications [12] [13] [14] [15] ( Table 1 ) have reported the successful use of LAMP-based protocols to test for SARS-CoV-2 RNA in serum, urine and saliva, as well as oropharyngeal and nasopharyngeal swabs (Table 2) , both with or without the requirement of viral RNA extraction [12] . Researchers have also used computed tomography (CT) scanning to diagnose COVID-19, demonstrating good diagnostic sensitivity (97%) relative to RT-PCR [16] . CT can assist in making a fast diagnosis, which can be helpful in the rapid isolation and treatment of patients. However, CT technology has inherent problems that limit its use in COVID-19 testing, especially in developing countries. First, it requires deep cleaning of the scanning suites to avoid potential contamination between examinations. This drastically slows patient throughput, a high level of which is needed in limited resource scenarios such as those found in developing countries. Second, and more importantly, contamination of the CT machine can potentially result in the infection of COVID-19-negative patients during scanning. Third, the trained radiologists required to examine the scans and diagnosis patients with COVID-19 are drastically lacking in developing countries. J o u r n a l P r e -p r o o f As an example, Nepal has very few working CT scanners relative to its 29 million population [17] [18] [19] . Developing countries have the fewest CT facilities per million population in the world, as the establishment of such facilities is costly [6] . However, at this point in the crisis, CT facilities dedicated to COVID-19 patients are required to diagnose suspected patients and meet the need for diagnostic resources in developing countries. Lack of trained manpower capable of performing the molecular bio logy experiments (e.g. viral RNA extraction) required to test for SARS-CoV-2 and interpret the results is another major limitation in the testing and confinement of COVID-19 in developing countries. For the few laboratory experts present in these countries, priority is given to other medical emergencies (e.g. heart attacks, road accidents). We suggest that training and workshops directed to COVID-19 testing and organized at a national and international level will be helpful in generating the necessary skilled manpower. The invitation of trained volunteers from the international community could be another option; however, in the scenario of a global epidemic and lockdown, receiving such rapid help from the international community is unlikely. Alternatively, the available manpower could learn from the expertise of the international community by video, audio, and other user-friendly tools and checklists developed by WHO and other international organizations, to make the process fast and efficient [20, 21] . Biosafety is the practice of safe methods for managing biological materials in the laboratory environment that are potentially hazardous or detrimental to health, to reduce or eliminate the exposure risk of laboratory workers and the outside environment [22] . Usually, biosafety in a laboratory is achieved by strictly following good laboratory operating practices (e.g., the prohibition of food, drink and smoking materials in the laboratory setting, use of biohazard warning signs); by the use of physical containment facilities (e.g., biological safety cabinets with high-efficiency particulate air filters, laboratory coats); by good laboratory design (e.g. easy to clean J o u r n a l P r e -p r o o f areas with no carpets or rugs); and by training in performing research involving biological agents. Biosafety is a major concern in the developing world as the mishandling of biomaterial has the potential to evoke another episode of pandemic. The WHO recommends that all the requirements of Biosafety Level-2 (BSL-2) or their equivalent are met at facilities handling COVID-19-related specimens and performing non-propagative molecular testing [23] . In many countries, including Nepal, there are very few laboratory facilities that meet the BSL-2 requirements for highly infectious diseases [24] . Establishing BSL-2-compliant facilities within a short time in an international lockdown situation would be difficult. Additionally, essential medical supplies, such as the gloves, masks, aprons, syringes and swabs necessary to maintain the safety of medical workers, are insufficient in developing countries. Lack of these supplies may hamper testing for the virus and further the spread the infection via poorly protected healthcare workers. The Nepal Ministry of Health [9] has recently authorized thirteen laboratories for COVID-19 disease-testing using PCR technology in the country which, considering that the population of Nepal is 29 million, is the equivalent to each laboratory serving 2.2 million people. The avian influenza control project had planned to construct eight laboratories (one central veterinary laboratory, five regional veterinary laboratories and one national avian disease investigation laboratory and one foot-and-mouth disease/trans-border animal disease laboratory) with BSL-2 facilities by 2011 [25] . According to a guideline produced by the National Public Health Laboratory (NPHL) [26] in Nepal, which is considered the authority on medical laboratory testing in the country, laboratories are categorized into five grades (A, B, C, D and E, with A denoting the highest and E the lowest category) depending on the available resources and the diagnostic facilities provided ( [29] . Similarly, additional training in good laboratory practices with respect to the highly infectious SARS-CoV-2 and the orientation of LAMP technology could be organized by the international community or national experts, generating skilled manpower to test for the infection at the available laboratories with BSL-2 facilities. Various prejudices exist among health workers in developing countries regarding epidemiological characteristics, animal reservoirs, risk factors and treatment strategies, particularly with false news and views now being circulated on social media platforms. The development of such notions from this type of news is demoralizing to health workers and may negatively affect the fight to diagnose and treat COVID-19. A campaign broadcasting clear, research-based scientific information and guidelines J o u r n a l P r e -p r o o f through authentic government media (e.g., radio, television) will help reduce stigma and misinformation around the virus. As well as enhancing manpower and infrastructure for testing of samples with suspected COVID-19, safety of patient biomaterials during storage and transportation both within a country and across international borders should also be secured. A proper channel involving the local health workers, transport machinery and laboratory scientists should be established in the light of international experiences (e.g., China). Furthermore, hotline-based contact with countries that are successfully fighting the virus (e.g., China) will also help in the fight against the outbreak. 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Interim Guidance Improved biosafety and biosecurity measures and/or strategies to tackle laboratory-acquired infections and related risks WHO, Laboratory biosafety guidance for novel coronavirus (2019-nCoV): Interim Recommendations 2 National State of the art report on biotechnology for Nepal.pdf.62600512c5db56594ae7bc6b3538ad26 World Bank, Nepal -Avian Influenza Control Project Guideline on Health Laboratory Establishment and Operational Criteria Registered Laboratories Number of Health Facilities in Nepal -Health Emergency Operation Center The Himalayan Times, Testing for coronavirus starts in Nepal The authors declare that there are no conflict of interest. Conceptualization: AKG, DRSBB; writing: AKG, DRSBB.All the authors have read and agreed to the published version of the manuscript.