Evaluation of Covid-19 country-wide testing capacity in Uganda

Evaluation of Covid-19 country-wide testing capacity in Uganda Project background, context and needs addressed Covid-19 Disease is arguably the most prominent pandemic of our time, having grown from a small outbreak in Wuhan province China to a global pandemic within just 3 months. This rapidly growing disease has left many dead, and even big economies pressed down on their knees and overwhelmed by cases. Whereas Africa has remained least affected, the World Health Organization (WHO) has consistently warned of dire consequences if community transmissions start in Africa where the health care systems are already weak(1). Indeed, community transmissions and sporadic cases have been reported in Africa, with more than 23,000 cases reported in 52 (96%) countries(2). In this regard, Uganda is not spared. As I write, there are 56 confirmed cases with over 5000 being monitored for Covid-19 symptoms(3). In response to the pandemic, countries have been plunged into lock-down with associated social and economic effects, people are advised to observe social distancing, there are restrictions on movement and also an emphasis on testing(4). Whereas these measures have been effective in countries such as China, the one shoe fits all approach may not work in Uganda and many other Low and Middle-Income countries where most people live from hand to mouth and live in crowded conditions. Accordingly, there is a need to reinforce these measures with a strategy of rapid and early detection for those with Covid-19, contact tracing and quarantine to limit exposure to the community. Indeed, this approach worked well for South Korea, a country where by early February 2020 had rapid community transmissions and used early testing and contact tracing as an approach to successfully limit the spread of the virus. When the first case was first detected in South Korea, the country made deliberate efforts to set up testing centers that were free of charge, increasing the capacity of the country to run over 20,000 tests a day(5). This ensured that 90% of the suspected cases and their contacts are tested and monitored to limit exposure to the community(6). Because of this approach, the country has successfully brought down the infection rates from 700 people per day to less than 10 people(7) as we write. Drawing from this success, countries are redesigning their strategy to adopt the South Korean approach to ensure testing facilities are available and accessible. More so, estimates suggest that about 80% of people with COVID-19 have a mild or asymptomatic disease, therefore, relying on symptomatic management will leave out asymptomatic individuals who are likely to spread the infection within the community(8). This provides a strong case for wide-spread testing of Covid-19. In Uganda, the government anticipates the national central testing facility to be overwhelmed by the ever-growing number of suspected cases together with their contacts and is moving to roll out the testing to regional centers, particularly regional referrals hospital laboratories and private laboratories. It should be noted that Covid-19 nucleic acid amplification tests require at least biosafety level 2 laboratories(9). Moreover, the currently available tests are molecular tests that include RNA manipulation and therefore full precautions associated with molecular assays. Whereas the move is set to greatly increase the accessibility to the test and eventually lower the turn-around time, the majority of the centers have never conducted molecular tests before and therefore their capacity in terms of human resources, and infrastructure remains questionable. It is basing upon this background that we propose to evaluate the Covid-19 testing capacity in the country. Aims or research questions being addressed To evaluate the country-wide diagnostic capacity of Covid-19 in Uganda Study Design This will be a descriptive cross-sectional study to evaluate the Covid-19 diagnostic testing of Uganda. Approach used to maximise the impact of research outputs, to improve health and the research community Sampling method Purposive sampling will be employed to select all the 16 Regional referrals hospital laboratories, 2 National reference laboratories and 5 private laboratories which have been earmarked as potential testing sites. Assessment tool An adapted version of the WHO Laboratory assessment tool (LAT) will be used for data collection. The WHO LAT is a generic tool that contains several modules (each assessing a laboratory core capacity) and indicators that can be adapted to evaluate specific core laboratory capacities(10). For this evaluation, we shall select 10 modules from the WHO LAT as follows; i)Documents, ii)Sample collection, processing and handling, iii) data and information management, iv) consumables and reagents, v) equipment, vi) laboratory testing performance, vii) facilities, viii) human resources, ix) biorisk management and x) public health functions of the lab). Each of the 10 modules has multiple indicators (ranging from 2-10 per module), which will be scored out of 100%. The module score will be calculated as an average of the indicator scores. The laboratory assessment score will be an overall average of the 10 module scores. The modules will be adapted to the Ugandan setting with slight modification of words to improve comprehension. Data collection and analysis Ethical approval will be sought from the Lira University Institutional Review Board (IRB) and thereafter the study will be registered with the Uganda National Council for Science and Technology. Research assistants will be trained on the use of data collection tools and then dispatched to collect data in a team of 2. A researcher administered questionnaire will be used to collect data from laboratory managers and an observation checklist will be used to collect data during laboratory inspection. The survey data will be double entered into an excel database and reconciled to identify inconsistencies and missing data. Data Dissemination plan Data dissemination is an essential part of our project and we propose to share research findings with policymakers and the wider scientific community. For policymakers, we shall avail and discuss a copy of the research report to the scientific committee of the Covid-19 task force in Uganda. For the scientific community, we shall publish the findings in a peer-reviewed journal, present at scientific conferences and make a copy available at the Lira University website. Expected outcome and significance To determine the Laboratory capacity, module scores will be rated as follows; strong (≥85%), good (70-84%), Weak (50-69%) and very weak (<50%). This will ultimately inform on the country-wide testing capacity of Covid-19 which is a central factor in pandemic control. Additionally, this data will identify core laboratory areas of strength which Uganda and other Low and Middle income Countries (LMICs) countries can benchmark to be better prepared for future epidemics. We shall also identify areas of weakness where technical persons, policy makers and partners can jointly address. Role in the project As a principal investigator, I will be responsible for the direct oversight and coordinating daily operations. This includes ensuring all the regulatory processes including ethical approval, registration, and administrative clearance is obtained, ensuring the study team is trained and that data collection and analysis are conducted to the required standards. I will lead the study team to share findings with all the relevant stakeholders including laboratory heads, policy makers, technical persons and the wider scientific community. References 1. Swalani S. COVID-19: Africa told to prepare for worst. What's the response? Al Jazeera2020 [cited 2020 7th April]. Available from: https://www.aljazeera.com/news/2020/03/covid-19-africa-told-prepare-worst-response-200319085112877.html. 2. African_Agurments. Coronavirus in Africa Tracker: African Arguments; 2020 [cited 2020 8th April]. Available from: https://africanarguments.org/2020/04/07/coronavirus-in-africa-tracker-how-many-cases-and-where-latest/. 3. MOH. Coronavirus (Pandemic) Covid-19 Kampala, Uganda: Ministry of Health Uganda; 2020 [cited 2020 8th April]. Available from: https://www.health.go.ug/covid/. 4. WHO. Basic protective measures against the new coronavirus: World Health Organization; 2020 [cited 2020 April 8th]. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public. 5. Fleming S. South Korea's Foreign Minister explains how the country contained COVID-19: World Economic Forum; 2020 [cited 2020 April 8th,]. Available from: https://www.weforum.org/agenda/2020/03/south-korea-covid-19-containment-testing/. 6. Levkowitz A. South Korea's Approach to Coronavirus 2020 [cited 2020 April 8th]. Available from: https://besacenter.org/perspectives-papers/south-korea-coronavirus/ 7. South Korea's new coronavirus cases fall to single digits: Al Jazeera; 2020 [cited 2020 April 21st ]. Available from: https://www.aljazeera.com/news/2020/04/south-korea-coronavirus-cases-fall-single-digits-200419031505830.html. 8. Anderson RM, Heesterbeek H, Klinkenberg D, Hollingsworth TD. How will country-based mitigation measures influence the course of the COVID-19 epidemic? The Lancet. 2020;395(10228):931-4. 9. WHO. Laboratory biosafety guidance related to coronavirus disease (COVID-19) Geneva: World Health Organization; 2020 [cited 2020 April 7th ]. 10. WHO. Laboratory Assessment Tool. Annex 2: Laboratory Assessment Tool / Facility Questionnaire: World Health Organization; 2012 [cited 2020 April 8th ]. Available from: http://www.who.int/ihr/publications/Annex2_en.xls?ua=1.