Who should be eligible for COVID-19 testing in South Africa? The answer to this differs depending on who you ask. According to a Spotlight report, while the current eligibility criteria for testing is clear, some people working in the field feel these criteria are too restrictive and should be broadened.
According to a National Institute of Communicable Diseases (NICD) brief dated 9 April 2020, criteria for persons under investigation (PUI) – those who should be tested for COVID-19 – are persons with acute respiratory illness with sudden onset of at least one of the following: cough, sore throat, shortness of breath or fever [> 38◦C (measured) or history of fever (subjective) irrespective of admission status].
According to Professor Adrian Puren of the NICD, “case definitions used by the NICD are informed by consultation with South African or international experts in the field and guidance from reputable organisations such as the World Health Organisation. The final definitions are reviewed by the Ministerial Advisory Committee and signed off by the National Department of Health.
“In the case of community screening the current criteria are (having) two respiratory symptoms,” he says.
But, the report asks, is there merit in broadening this criteria, for example for anyone displaying just one symptom or for all persons admitted to hospital regardless of respiratory illness status?
“The NICD has revised its criteria for testing as the epidemic has evolved,” says Puren. “The NICD took pragmatic decisions based on the knowledge available at the time as well as the availability of resources (both human and testing reagents/platforms). The case definition is a guide and the doctor and patient will always review risk and make a decision on whether to test or not on an individual case-by-case basis.”
Dr Tom Boyles, an infectious diseases specialist based at Helen Joseph Hospital in Johannesburg, says in the report that there is merit in broadening the criteria. In fact, he and his team, who are assessing the readiness of a number of clinics in the city to combat COVID-19, are testing anyone displaying even one of the four symptoms. Why is the country testing at lower rates than envisaged? Is it a capacity issue or is it down to the eligibility criteria?
Professor Shabir Madhi, director of the South African Medical Research Council’s Respiratory and Meningeal Pathogens Research Unit, says it is both. “It’s both due to the number of people meeting the eligibility criteria and a number of other reasons. For example, the roll out of community testing only started very recently, just before the Easter break, and we haven’t been able to ramp it up to full scale.
“There are a number of bottlenecks, such as staff training which is ongoing, as well as the materials that are required for testing being in short supply. The one constraint is that swabs and material needed for testing in the laboratory are in short supply,” he told Spotlight.
According to Madhi, community testing should have been started long ago. “We should have been doing that right at the start of the lockdown.”
But should we be testing every person who is admitted into hospital instead of only those with respiratory illnesses? “We could make a case for testing everyone in hospital settings. In the US, one study done on women coming into hospital to give birth showed that about 15% of them were infected and 80% of these were asymptomatic,” says Madhi.
However, he says the risk with this would be that resources to test symptomatic individuals in the community could be diverted to asymptomatic patients in hospital.
The report says University of KwaZulu-Natal’s Professor Andy Gray sums up the situation. “The obvious con to testing more widely is the impact on the laboratories, which could be overwhelmed, consuming resources and delaying results for positive cases. Delayed results mean more PUI under isolation, which could also overwhelm that capacity. The pros to more liberal testing, if resources and capacity allow, is that milder cases may be diagnosed, interrupting transmission, and a better idea of true incidence obtained,” says Gray.
[link url="https://www.spotlightnsp.co.za/2020/04/24/covid-19-is-sas-testing-criteria-too-restrictive/"]Full Spotlight report[/link]