Timely Detection of SARS-CoV-2 in Limited Resource Settings: The Role of the Laboratory in Zimbabwe

*Joyce Namulondo, Muchaneta Mugabe, Zinyowera Sekessai, Prisca Chikwanda, Phibeon Munyaradzi Mangwendeza, Raiva Simbi, Barbara Manyame, Anafi Mataka, Allen Matubu, Justen Manase, Anderson Chimusoro and Alex Gasasira*

## **Abstract**

The recommended approach for response to severe acute respiratory syndrome coronavirus 2, was to test to enable timely detection, isolation and contact tracing so as to reduce the rapid spread of the disease. This highlighted that the laboratory as one of the core capacities of the International Health Regulations and key technical area in the International Health Security was critical in curbing the spread of the virus. Zimbabwe embarked on testing for SARS-CoV-2 in February 2020 following the guidance and support from WHO leveraging the existing testing capacity. Testing was guided by a laboratory pillar which constituted members from different organizations partnering with the Ministry of Health and Child Care. SARS-CoV-2 testing expansion was based on a phased approach using a tiered system in which laboratory staff from lower tiers were seconded to test for coronavirus using RT-PCR with National Microbiology Reference Laboratory (NMRL) being the hub for centralized consolidation of all results. As the pandemic grew nationally, there was an increase in testing per day and reduction in turnaround time as five laboratories were fully capacitated to test using RT-PCR open platforms, thirty-three provincial and district laboratories to test using TB GeneXpert and 5 provincial laboratories to use Abbott platforms.

**Keywords:** pneumonia, detection, laboratory expansion, testing, partner coordination

#### **1. Introduction**

Coronavirus Disease 2019 (COVID-19) as it came to be known, was first reported as a novel pneumonia in Wuhan, China in December 2019 [1]. It was eventually shown to be caused by a coronavirus strain known as the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [2]. This disease was declared a Public Health Emergency of International Concern by the World Health Organization (WHO) on 30th January 2020 and eventually a pandemic on 11 March 2020. Africa experienced its first COVID-19 virus case on 14th February in Egypt [3]. This was an Italian citizen returning from Milan and had mild symptoms. South Africa a neighboring country to Zimbabwe had its first case confirmed on the 5th of March 2020 and this was also an Italian returning from Italy with mild symptoms identified on visiting a private general practitioner to consult for some symptoms [4]. Zimbabwe and other neighboring countries were at a high risk of importing cases and subsequent community spread of COVID-19 cases owing to the border trade activity with South Africa. SARS-CoV-2 presents differently among individuals in different population. The majority of cases in the African population present with asymptomatic to mild symptoms with few symptomatic cases [5]. People with severe forms of the disease mostly present with pneumonia and difficulty in breathing which may sometimes require mechanical ventilation [6]. SARS-CoV-2 infection is spread through contact and exposure to droplets and aerosols of viral particles from infected persons coughing, sneezing and talking [6, 7]. Therefore, the main prevention method for spread is by practicing hand hygiene through frequent hand washing with soap or alcohol based hand sanitizer [8, 9] and use of face masks as guided by WHO [10]. In order to control the rate of infection, it is important to put in place active disease surveillance for early identification, isolation and contact tracing [11, 12]. The detection of COVID-19 is largely based on the laboratory identification of SARS-CoV-2 virus [13, 14] hence the need to increase laboratory capacity for testing of suspected cases, in order to isolate cases and their contacts from the healthy population to reduce the spread.

The COVID -19 pandemic presented a huge demand on the laboratory compared to previous emergencies and at a time when most low-middle income countries were not well capacitated to respond to outbreaks/pandemics [14]. Laboratory being among the core capacities of the International Health Regulations, IHR (2005) plays a critical role in the timely response to emergencies [15]. Laboratory is a key technical area of International Health Security enabling countries and entities to detect infectious agents of human or animal origin, enhancing preparedness and response to infectious diseases of epidemic potential [16, 17]. Efficient diagnostic strategies and methods ensures timely detection of the virus [18].

Globally, SARS-COV-2 can be detected most reliably using Real-Time Polymerize Chain Reaction (RT- PCR), a highly sensitive molecular technique for viral nucleic acid detection using a number of different in-house as well as commercially available kits. Antigen and antibody based rapid diagnostic tests (RDTs) are less sensitive and also used as directed by testing strategies developed by the country's health regulatory authorities as recommended by WHO [19, 20].

The COVID-19 pandemic brought in a new dimension to international health security bringing new dimensions of solidarity [21] and selfishness in certain situations. These issues were more marked in the laboratory side of the preparedness and response efforts. First, to develop COVID-19 diagnostic testing, there was a need to share the viral material in line with the pandemic influenza preparedness plan [22] as well as the Nagoya Protocol [23]. This was done, according to WHO. Secondly, the development and distribution of diagnostics brought in a crunch with countries with capacity for development of these resources prioritizing themselves to the detriment of poorer countries with less capacity. This would then be improved with a solidarity movement spearheaded by WHO, which pooled organizations and entities involved in the response for centralized procurement and allocation of resources to countries in need. This saw the development of the online platform, COVID-19 supply portal [24] where countries could layout their requirements and have allocations from the global level according to their need and availability.

*Timely Detection of SARS-CoV-2 in Limited Resource Settings: The Role of the Laboratory… DOI: http://dx.doi.org/10.5772/intechopen.96629*

Like most of the Low to middle-income countries (LMIC), Zimbabwe started testing for SARS-COV-2 in February 2020 without a clear strategy for testing with support from WHO and Africa CDC. At this point, there was one laboratory staff at National Microbiology Reference Laboratory (NMRL) trained at NICD in South Africa (facilitated by Africa CDC) on testing for COVID-19 with only 5 tests being done a day. The available capacity for influenza surveillance in terms of staff and HIV surveillance in terms of equipment and laboratory consumables became the initial basis for COVID-19 testing. The first case of SARS-COV-2 was detected in Zimbabwe on 20th of March 2020 where a male traveler of 38 years of age traveling from UK to Victoria Falls, had mild symptoms and tested positive for SARS-COV-2. At this time, there was a great need to establish a strategy to expand testing to meet the country's needs before cases increased [25]. The speed at which WHO developed guidance document on the onset of the pandemic provided an opportunity for countries including Zimbabwe to ride on to develop their country testing strategies.

In this report, we showcase Zimbabwe's hands on experience in scaling up testing for COVID-19 using RT-PCR since the start of the response in February 2020 following a step by step tier-based approach and highlighting the major challenges identified along the process and key lessons learned from this experience.
