Coronavirus

Testing, testing, 123: Unpacking the confusion around SA’s Covid-19 testing

By Rebecca Davis 19 March 2020

A doctor shows a test kit for coronavirus samples at the Central Public Health Laboratories in Cairo, Egypt, 16 March 2020. (Photo: EPA-EFE / Mohamed Hossam)

Pandemics spark panic, and Covid-19 is no exception. One effect of this in SA is the high volume of people who want to be tested for the coronavirus. But as the country’s laboratory service risks buckling under the strain, health authorities are pleading for the limited stocks of tests to be reserved for those who are genuinely high risk.

When 40-year-old Mary* stepped off her flight from South America at OR Tambo International on Friday 13 March, she was already feeling a bit unwell. Given a health screening form to complete before she passed through immigration, Mary dutifully noted down her symptoms: scratchy throat, headache, fluey.

Covid-19 was on her mind. Since leaving South Africa on 12 February, Mary had taken a total of 12 flights during her month away spent researching for a work project. Her travelling was confined to South America, which is not considered a high-risk zone for the coronavirus. What worried her more was the amount of time she had spent over four weeks in airports, crammed into confined spaces with international travellers, during the period when Covid-19 spread to the status of a global pandemic.   

Perhaps the person who would collect her health screening form at the airport would be able to tell her whether her concern was justified, she thought. But it didn’t work out that way.

“I was waiting for someone to ask to see my form and nobody did,” Mary told Daily Maverick.

“Everyone filled out this amazing thorough form, and then we just walked through immigration without anyone collecting them.”

When Daily Maverick contacted Department of Health spokesperson Lwazi Manzi for comment on this, Manzi expressed surprise – pointing out that journalists, MPs and the president have all been taken on inspection tours of the screening measures in place at entry points like OR Tambo. Since 35 of South Africa’s ports of entry have also been closed, the staff from those ports have been redeployed to the open ports, along with additional military personnel to help with screening.

Commenting on Mary’s experience, Manzi said: “That’s not what’s supposed to happen. What we expect is that questionnaires are collected and analysed. But one thing that will never happen is that you’ll go through our airports without some kind of screening, even if you aren’t aware of it.”

Mary flew from Johannesburg home to Cape Town. Over the weekend, her symptoms intensified in tandem with her worry. She phoned the government’s Covid-19 hotline, where she says she was told that she needed to see her GP to obtain a referral to get tested. After a telephonic consultation, her doctor told her to report to her nearest Mediclinic – Cape Town Mediclinic in Gardens, central Cape Town – for testing.

But when Mary called to make an appointment, she was horrified to be told that the total cost of testing would amount to over R3,000: “R1,500 for the doctor, R700 for the hospital and about R900 for the test”.

Mary tried the Covid-19 hotline again. After describing her circumstances to a different operator, she says she was told: “Okay, yes, you need to be tested. Go to your nearest emergency room, public or private hospital, as soon as possible.”

That didn’t sound right to Mary, who was losing faith in the official processes and the validity of their information. She had read that the coronavirus was highly infectious. If she just rocked up to ER, wouldn’t she risk infecting other sick people waiting for treatment?

Mary’s father offered to pay for the Mediclinic test, so she decided to go with that option despite its exorbitant expense.

“I had to do it as soon as possible because I have people I live with who need to know if they can get back to their lives,” Mary said.

At Cape Town Mediclinic, which Daily Maverick visited on Wednesday, best practice was being followed. People arriving for coronavirus tests were directed away from the main hospital building to a marquee set up in the parking lot and given masks upon arrival. They queued by sitting on chairs spaced at intervals of at least a metre, and there was constant sterilisation of equipment happening.

Mary is now awaiting the results of her test, which is why Daily Maverick is not naming her to protect her privacy. She was told she would get her results in 48 hours. But what is still weighing on her mind is the cost of the procedure, which would be unaffordable for most South Africans – and the fact that she was required to jump through hoops to carry out what she considered to be the most responsible course of action.

“The reason why I was really eager to test myself is that I think I’m quite healthy, but I need to know if I’m a carrier – since I have travelled and I have the symptoms,” Mary says.

***

Mary’s story is typical of a number of current concerns for South Africans: a fear that the official measures in place (eg airport screenings) are not rigorous enough; a desire to be tested in order both to allay one’s personal concerns and behave responsibly in society; and a frustration that the processes around this seem to be unnecessarily confusing, laborious and expensive.

These concerns have been fuelled by mixed messages from authorities. Internationally, the edict is now that countries must test for the coronavirus as quickly and widely as possible, as the World Health Organisation stressed on Tuesday. But in South Africa, as will be seen, there are severe restraints on the ability to do this.

The imperative of social distancing and the instructions to avoid physical contact, meanwhile, have given rise to the perception that even the most fleeting exposure to someone who has tested positive may be enough to transmit the virus. This is not accurate.

Mary’s fear that her trip to a public hospital’s ER could endanger others is understandable in a context where even South African healthcare workers are unsure of the relevant protocols.

On Wednesday morning, a GP phoned into 702 to ask National Institute of Communicable Diseases (NICD) director Lynn Morris what he should do if a patient he inspected went on to test positive for coronavirus. Should he quarantine himself?

Morris explained that if the doctor was wearing protective equipment when he consulted with a potential coronavirus case, there would be no need to quarantine himself afterwards.

“Close contact” – the kind which can expose you to risk – is defined as being within one metre of a coronavirus-positive person without wearing protective gear for at least 15 minutes, Morris said.

The Department of Health’s Manzi told Daily Maverick that health services are being inundated with concerns from people who say “my sister’s friend’s colleague” has tested positive, and therefore they might be positive too.

The volume of calls to the Covid-19 hotline has been so high – 324,062 calls to date – that the NICD has had to add two additional hotlines.

Now local health authorities are pleading with the public: don’t get tested unless you are at high risk.

The NICD has spelled out the current criteria for testing: that only those who have developed some respiratory symptoms and have either returned to South Africa from countries with local transmission within the last 14 days or have had close contact with a confirmed coronavirus case should be tested for Covid-19.

There are three main reasons why it is imperative that testing in South Africa be reserved for those who meet the criteria: the expense, the limited availability of tests, and the limited resources of the laboratories which have to conduct the coronavirus testing while also performing their normal duties.

Though there have been reports that South Africa’s test stocks are already running dangerously low, both the NICD and the Department of Health say this is not true.

Acting director-general of the health department Dr Anban Pillay told Daily Maverick that South Africa has sufficient testing kits in both the private and the public sectors if the “worried well” – people who are merely anxious but neither symptomatic nor aligned to the case definition for a possible coronavirus positive – don’t flood labs with demands to test.   

More than 3,000 coronavirus tests have been conducted by private and public laboratories in South Africa so far, of which 116 have returned positive as of the latest figures given on Wednesday 18 March 2020.

On 702, Morris paid tribute to the efforts of private laboratories in helping to ramp up testing, but also warned that needless tests could overwhelm the system.

“I realise there’s a lot of anxiety and a lot of people who are asymptomatic want to be tested. But right now it’s not indicated. I’m pleading with the public not to present themselves for testing if they don’t have symptoms,” Morris said.

The decision of medical aids like Discovery only to pay for coronavirus testing if the test returns positive has caused outrage on social media. But it also provides a necessary disincentive to seek testing if it’s unlikely that you’re at risk.

“The anger around ‘Why won’t Discovery pay?’ is not justified,” says Professor Francois Venter, one of South Africa’s most eminent virologists.

“There is an extremely limited number of tests, which is why we have to be careful and focus on symptomatic patients. If everyone who wanted a test could get one, it would collapse the laboratory system and bankrupt medical aids,” Venter told Daily Maverick.

Another reason why only patients experiencing symptoms should be tested is because the results can otherwise be misleading.

“Asymptomatic patients with Covid-19 may in fact test negative, before they become symptomatic, and hence the testing protocol as directed by the NICD must be followed,” Discovery Health CEO Ryan Noach told Daily Maverick.

But the high cost of private-sector testing remains a concern. Mediclinic failed to respond to Daily Maverick’s query about the R3,000 charge for a test quoted to Mary.

Health DG Anban Pillay told Daily Maverick, however, that Health Minister Zweli Mkhize has been in talks with private laboratories like Lancet and Pathways to get them to zero-rate the cost of coronavirus tests.

“We are asking them to charge what it costs,” Pillay said. The NICD says the actual cost of a test, including the testing kit, is R300. Private labs are charging between R900 and R1,400.

***

Looking at Mary’s experience again helps illuminate the ways in which South Africa’s testing system is both working and failing.

Both her GP and the Covid-19 hotline operator correctly assessed that Mary was probably in the small category of South Africans who met the clinical criteria for testing: having travelled within 14 days and exhibiting flu-like symptoms.

Although Mary distrusted the advice of the Covid-19 operator to report to a public hospital for testing, the recommendation was half-right. It would have been unwise for Mary to present herself in an emergency room without forewarning the facility, but public hospitals should have protocols in place to handle this situation.

Manzi cites Tygerberg Hospital in Cape Town as the “gold standard” for the protocol: 

“You phone ahead, they tell you you must park here, access this part of the hospital, we will see you. They already have a section of the hospital set aside. Everyone is dressed in [protective gear]. They quickly manage you, take your history, administer the test, you’re back home in no time quarantined. That is what we expect.”

The Cape Town Mediclinic – according to Mary’s account and Daily Maverick’s observation – appears to be handling the testing procedure well, by separating the process from the general hospital, distributing protective gear, constantly sanitising surfaces and ensuring patients are kept at a distance from each other.

It should be noted, however, that this might not be the case everywhere. Daily Maverick has heard reports of other private clinics keeping patients waiting to be tested in close quarters in a room where equipment like pens was shared.

Experts are agreed that the single most important piece of advice potentially coronavirus-positive people can be given is to self-isolate.

Professor Venter says, in fact: “Self-isolation is far more important than testing.”

Worryingly, Mary says that at no point before or after her testing was she advised to self-isolate – although she is doing it anyway as a precaution.

“I wasn’t given any instruction when I left,” she told Daily Maverick.

Another Cape Town woman interviewed by Daily Maverick who has tested positive for coronavirus, however, said that the Department of Health was doing a reasonable job in terms of post-test support.

“The health department phones us a few times a day and checks on us,” she says.

“But there is still a lot of confusion around what we should be doing. The department is trying their best but it doesn’t feel like there’s a lot of clarity.”

Clarity may be hard to come by for some time in a situation where the context of the disease is constantly shifting. As more cases of local transmission emerge, for instance, Manzi says that it is likely the criteria for testing will shift, and the requirement of recent travel will grow less important.

“We will keep revising the clinical guidelines on who can get tested,” she says.

But for now, health authorities are very clear on one point: only seek testing if you meet the NICD criteria. DM

*Pseudonym to protect identity

Additional reporting by Ferial Haffajee.

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