COVID-19: To test or not to test

Widespread testing of individuals – not only those showing symptoms – will reveal the true situation of the pandemic and allow epidemiologists to predict and control the spread. SADE OGUNTOLA, speaks with experts who explained the necessity for the  coronavirus (COVID-19) test and why it matters for policymakers and individuals in general.

THE controversy started when 56-year-old Susan Idoko-Okpe who got back from the United Kingdom (UK) claimed that she had been quarantined by the government since March 24 without any evidence that she was infected with COVID-19. According to her, 46 days after she was quarantined first in Benue, then at the National Hospital, Abuja, the Federal Government refused to produce the test result showing that she was positive.

She alleged that the medical report upon which she was quarantined belonged to a 62-year-old woman, Sarah Okpe, from the Otukpo LGA. She claimed the owner of the report was tested in Benue for the virus on February 28, while she was still in the UK and that she arrived in Nigeria on March 22 only to be quarantined based on the February 28 medical report.

Basics of testing

The issue therefore has been whether or not the test to determine the status of an individual by officials of Nigeria Centre for Disease Control (NCDC) is real or genuine. Sunday Tribune investigation revealed that there is a COVID-19 test.

According to the findings, there are two broad categories of test. While some look for the presence of the virus, like the reverse transcription polymerase chain reaction (RT-PCR) test, others look for the antibodies which arise when a body is attacked by the virus.

But testing for a new disease, according to medical experts, will always have teething problems. Virus testing is key for diagnosing and for tracking the epidemic. It’s the only way to uncover just how many people have been infected or could infect others.

But according to two medical doctors (names withheld) that were tested by the Oyo COVID-19 Emergency Operation Centre, their experience with COVID-19  is different from these. Both had had contact with individuals that turned out positive for coronavirus while at work in the hospital. Therefore, their experience going for the COVID-19 testing was different.

According to one of the doctors, “I have been on self-isolation as advised by Oyo COVID response team and only took the test on day 14.  All I produced at the testing centre at Adamasigba was an initial code generated by the Oyo COVID response team.”

He explained that nasal and throat swabs were taken. “It is not painful; you only feel some discomfort because it involves swabbing cavity between the nose and mouth for 15 seconds and rotating the swab several times.”

Certainly, he was not afraid of taking the test. But, he added, “I wouldn’t have gone if I had probably not had a potential exposure. I don’t think anybody should be afraid of going for the test. Certainly, nobody wants to test positive but it is better if to find out if you are positive to be able to stop its transfer to others.”

Sharing his experience, he said after arriving at the testing centre at Adamasigba, he had to wait another three hours for a code to be generated for him by Oyo COVID-response team before he could access the test. COVID-19: to test or not to test

Although the reception at the testing centre in Adamasigba was good, he felt stigmatised by the way he was  interviewed. The person, he claimed acted as if she was about to run away from him.

“The safe distance individuals are supposed to maintain is two metres. If you are putting on personal protective equipment, you don’t expect to be infected and more so the person you are speaking it was a contact. I was really stunned by the woman. You can barely hear the woman from the distance when she was talking with me. I was shocked,” he stated.

But the second doctors’ experience was quite different. The doctor with a bias for women’s health got exposed while in contact with his colleague that was confirmed to have COVID-19. It was a significant exposure, so had to go for the test.

His sample was taken at the parking lot of UCH, Ibadan because he did not want the stigma that comes with people knowing that he was tested for COVID-19.

His complaint also was on the pressure put on him when filling a questionnaire to ascertain his level of exposure and contacts.

“They kept asking me to give out numbers of several people that I have had contact with and I told them it was only my wife that I had significant contact with. It almost became a fracas.”

He claimed his refusal to give just anybody’s contact was to avoid people being embarrassed by calls in case his result came back positive.

“It was embarrassing to me when an index case who gave my number and they called. I understand that we had significant contact that was not an issue. But how will I now give the contact of people who have not been exposed.”

Getting tested in Nigeria had been fraught with many challenges, including misinformation on the infection, few testing centres, fear of the unknown, the complexity of collecting samples, timing and inadequate expertise to do the tests accurately.

Some clinicians have raised questions about the accuracy of available COVID-19 tests and the need to increase testing centres.

Mid-April, Director-General of Nigeria Centre for Disease Control (NCDC), Dr Chikwe Ihekweazu, had announced that the agency was  to repurpose a set of equipment designed for HIV and tuberculosis tests to accelerate COVID-19 testing. At the time, NCDC’s test procedure for COVID-19 relied on a semi-automated real-time PCR process that delivers results between three and eight hours. The new system is expected to significantly reduce testing time.

He had explained that based on WHO recommendation specimen would be collected from the upper respiratory tract using the nasopharyngeal swab technique – in which a sample is gathered from the throat behind the nose, containing a mixture of mucous and saliva.

The samples are then tested for SARS-CoV-2 using a real-time reverse-transcription polymerase chain reaction (rRT-PCR) assay – a method used to detect the presence of «specific genetic material from a disease-causing germ».

“The bottleneck is not about the testing capacity in the lab. It’s the efficiency of collecting the right samples from the right patients and bringing them to [NCDC’s molecular] labs.” Ihekweazu said.

Nigeria now has 17 labs for COVID-19 testing, an improvement on the five labs that existed as at the date of the first confirmed case. There are plans to cite labs in all 36 states and the federal capital territory.

Dr Ihekweazu said with the first set of equipment supplied already, these kits are expected to supplement the real-time PCR process currently used. To a large extent, this recent move will help speed up test result time by 50 per cent.

But how are the tests conducted? According to Sunday Tribune findings, two kinds of tests are available for COVID-19: viral tests and antibody tests. An antibody test may not be able to show if you have a current infection, because it can take between one and three weeks after infection to make antibodies.

Dr Yemi Ojo, Press liaison officer, Risk Communication and Social Mobilization pillar of Oyo State Emergency Operation Centre, in Oyo State, explained the process saying to have COVID-19 test is easy. According to Dr Ojo, such an individual is resident in Oyo State he or she must have been a close contact with a COVID-19 index case or having signs and symptoms of COVID infection such as cough, cold and catarrh.

«There is a drive or walk through at Adamasingba Stadium for the general public to get tested. Also, officials of the EOC go to take testing samples of individuals that are very sick at their homes.

«The EOC has four telephone lines that the public can call in. They will explain how to go about it. A link is sent to the person’s phone to fill a form online to generate a code. Individuals can also be helped to fill the form at the EOC call centre.»

After sorting the cases, Ojo, a public health expert, said the EOC decides those to have their tests at the Adamasigba Stadium drive-in or at home. Testing at home is done very discreetly to prevent stigmatization. The result of the test is sent by SMS with their codes after they are ready.

Professor Bayo Onajole, a public health physician and epidemiologist at the Lagos University Teaching Hospital (LUTH), points out that test is adjudged based on their specificity and sensitivity for a particular disease.

Sensitivity talks to how well the test can detect the presence of a disease. Specificity tells how well the test can confirm a disease. A low specificity would mean that many cases of infections will be missed. They will get positive tests when they aren’t actually infected.

A true negative is when the test is negative and no infection is present. A false positive is when the test is positive but there is really no infection.

Some tests are highly sensitive but not highly specific while some are highly specific but not highly sensitive. Professor Onajole said for the COVID-19 virus, the polymerase chain reaction (PCR) is more highly specific in terms of testing than say a Rapid test kit for the same disease.

He, however, declared that both the PCR test and the Rapid test kits for COVID-19 virus have an advantage and a disadvantage in the detection of the virus.

Professor Onajole cited temperature measurement using the infrared thermometer as a very sensitive test to determine those probably with COVID 19 virus, although it is not specific.

“The PCR is then applied to confirm whether the temperature elevation is as a result of coronavirus or not. The PCR is a more specific test for the virus. It is about 98 or 99 per cent specific, so its margin of error is very little,” he added.

Howbeit, Professor Onajole said that test of the 56-year-old Susan Idoko-Okpe in Benue is highly political. Part of the problem was that the lady was not convinced that she had COVID-19 and saw her rights being infringed on.

“I was not there, but naturally they need to repeat the test until they get a negative one before they release the person whether the person is symptomatic or not.”

The lady was reported to have refused to conduct any other tests. She was not convinced that she had COVID-19 because she has no symptoms.  But an individual can be infected but yet asymptomatic, and able to infect people around her unknowingly.

According to Professor Onajole, there is the need for everybody to be tested but there are no enough test kits, as such the need to prioritize who could have the test.

“Even in America and the UK, they need to scale up testing. But they also do not have enough test kits to go round everybody. So they have to set up criteria to determine who should be tested and who shouldn’t be tested. It does not mean that everybody should not be tested, but you have limitations,” he added.

Professor David Olaleye, a virologist at the NCDC coronavirus diagnostic centre in its College of Medicine stated that the result of tests from the 17 NCDC laboratories nationally are accurate, reliable and reproducible.

He said “one of the best things that NCDC did at the onset was developing a protocol that has very strong internal control system, that validates these results.

“At the NCDC laboratories, about 17 in all, the kit that they used is first validated by the NCDC in their laboratory in Abuja and I and other scientists have been part of validation in other laboratories.

“Of course, there are situations that you can have false positives or false negatives. But as much as the method we use in Nigeria, it should be very rare because of this control system that I mentioned,” he added.

On the controversy generated by 56-year-old Susan Idoko-Okpe COVID-19 report, Professor Adeleye, said everything cannot be said to true until the other side of the story is known.

“The doctor that referred her or arranged the testing must have noticed one thing because she returned from the UK. That made her the subject of interest. You and I know the magnitude of the infection in the UK is high. That is also the guideline form NCDC and Federal Ministry of Health.”

Nonetheless, he said the take home message for Nigeria on the incident is to ensure disclosure of test results to the affected individual first before such is made available to the public.

Professor Olaleye, however, said ensure that an individual with the infection can be treated in an isolation centre is for their good as well as that of the public.

According to him, “primarily they can observe and manage the persons’ health and also prevent the infection spreading from the person to others. The guidelines say you must have two consecutive negatives test before you are allowed to go back home.”

The new proviso to it, he said, is that after they are discharged, they are also supposed to register on an outpatient basis with the hospital for further medical care.

“They give an appointment for the individual to come for a check-up just like they like any patient that is discharged from the hospital, but a lot of people may not do so,” he stated.

Implication of testing negative

What does testing positive or negative for coronavirus infection mean? Oyo State coordinator of isolation centres and a member of the state Coronavirus Taskforce in Oyo state, Professor Temitope Alonge said “when you use the positive or negative, it means that the viral load, the quantity of virus in the body is reducing. It is not to say that the body has completely eliminated the virus.”

Alonge, a former, Chief Medical Director, University College Hospital (UCH), Ibadan, said the only time when the person has eliminated the virus or can combat the infection is when the person has developed an antibody to fight the virus.

Professor Alonge said “it is not a virus that stays in the body forever, not like HIV. A patient can be positive today, and tomorrow if the viral load had gone down, he is negative.”

However, if at the time of infection with coronavirus, a person’s body immunity is low, the possibility of having COVID-19 symptoms are higher. Also, individuals with previous diseases such as diabetes and hypertension also stand a higher chance of the body succumbing if exposed to coronavirus.

Professor Alonge explained that treatment of individuals with COVID-19 is aimed at helping the body to boost its immunity and clear the infection in the throat and sinuses with drugs, including vitamin C, zinc and antibiotics.

Certainly, cases of COVID-19 are rising in Nigeria. Accompanying daily developments has been a rise in panic levels fuelled in many cases by misinformation, but despite that more rapid and widespread testing remains pivotal to keeping everyone safe from the COVID-19 pandemic.

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