COVID-19: Doctors concerned about severe testing delays

COVID-19: Doctors concerned about severe testing delaysPHOTO: Gauteng Health
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South Africa’s scaling up of COVID-19 testing in recent weeks appears to have resulted in severe capacity constraints at public sector laboratories, with doctors reporting that it is often taking a week or longer to get results.

“The current turnaround time for COVID-19 tests in Gauteng is around 7 days for outpatients and 3-4 days for in-patients,” says Dr Tom Boyles, an Infectious Diseases specialist at Helen Joseph Hospital in Johannesburg. He says that colleagues from the Eastern and Western Cape have reported similar delays.

A doctor who works at an emergency unit in a public sector hospital in Johannesburg confirmed to Spotlight that they are waiting seven days for COVID-19 test results. The doctor who asked not to be identified, says that the situation is very frustrating for clinicians. In some of the worst cases, tests sent from their hospital were lost and no results were provided as long as three weeks after initial testing.

The doctor says that testing delays are contributing to wards filling up, since they are not getting the results that would give the all-clear for patients to be discharged. The doctor also suggested that the testing backlog may explain why the official count of confirmed cases in Gauteng is not rising more quickly at the moment. “I think it’s simply because we are not testing enough,” the doctor said. “Our numbers reflect a week ago.”

Spotlight has also received information that COVID-19 test turnaround times at another Johannesburg hospital is currently 11 days.

Questions Spotlight sent to the National Health Laboratory Services were not answered by the time of publication, but Business Day this morning quoted NHLS CEO Kamy Chetty saying that the key constraint was the supply of test kits. “The suppliers for the high throughput machines do not have enough stock to meet demand and are trying to ramp up production,” she is quoted as saying.

This appears to contradict earlier reassurances given by NHLS board chair Eric Buch. At the beginning of April Buch confidently told Spotlight that the NHLS had the capacity to do 15 000 tests a day. “The NHLS has also secured supplies to maintain the 15 000 testing capacity over the next three months and further increase it if required,” he told Spotlight at the time.  At the time Buch also said that “the NHLS cannot generate demand, and in fact would welcome an increase in the number of patients who are referred for testing”.

Over the last week the NHLS plus private sector labs have together done between 10 000 and 15 000 tests a day – a substantial increase from much lower levels two weeks ago. Even so, information provided in Health Minister Dr Zweli Mkhize’s daily COVID-19 updates suggests that the public sector (NHLS) has not yet done anything near the 15 000 claimed daily capacity.

Impact on services

Boyles says that the delays are having a huge impact on service delivery, “particularly as there are currently no isolation facilities to house people who cannot self-isolate due to crowded living conditions”.  “Therefore, an outpatient with mild disease may go back to a crowded living space or even to work and only be informed that she is positive 7 days later when she has most likely already transmitted the infection,” says Boyles. “There are similar problems for inpatients as there are not enough single rooms to isolate them all. While awaiting results, positive and negative
patients must share wards. While every effort is made to prevent cross-infection, the greater the turnaround time the greater the risk.”

Democratic Alliance shadow MEC for Health in Gauteng, Jack Bloom, shares these concerns. “I am alarmed by delays in providing test results in Gauteng which means that many COVID-19 infection figures could be a week old and infected people could be infecting others instead of being quarantined,” said Jack Bloom in a media statement released this morning. “I fear that the COVID-19 infection figures in Gauteng are understated because of testing backlogs. If public testing cannot cope then private tests should be commissioned by the provincial government as is being done in the Western Cape.”

Questions sent to the Gauteng Department of Health were not answered by the time of publication.

At a media conference on Thursday Dr Keith Cloete, head of the Western Cape Department of Health, said that in some instances the testing turnaround time in the province was seven days, but indicated that it was now down to around two days. He said that the Western Cape had taken a decision to use private sector testing capacity. He also indicated that the province’s Premier and MEC for Health had written to the President and the National Minister of Health about the province’s concerns around the country’s testing capacity.

Cloete said that the recent scale-up in testing exceeded the NHLS’s capacity to keep up with demand. Boyles made a similar point, saying that the NHLS was “clearly being overwhelmed at the moment”. He also questioned how transparent the NHLS was being about their capacity challenges.

What to do?

While Chetty told Business Day that the NHLS is “working hard” to address the supply issues, the limited testing capacity may in the meantime require a rethink of South Africa’s testing strategy.

Boyles suggests three things:

1) Stop community testing of asymptomatic people – the yield on results is very low, and it floods the systems with tests that it cannot handle. This can be restarted when laboratory capacity improves. Alternatively, in such circumstance’s samples should be pooled such that a single PCR can be used for 5 to 10 patients. This is already standard practice in other countries.

2) Prioritise inpatient samples, they should go to the front of the queue in the laboratory, meaning that the turnaround time would be less than 24 hours.

3) Provide isolation facilities for outpatients who live in crowded conditions, to be safely housed while awaiting results.

Cloete hinted at a somewhat similar prioritisation of testing in the Western Cape. He identified five different testing streams, of which he stressed the urgency of short turnaround times for the first two in the list below.

1. Persons under investigation (PUI) in an acute hospital setting,

2. Healthcare workers,

3. Members of the public who present with symptoms,

4. People identified through community screening, and

5. Workplace clusters.

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