Covid-19 testing needs a new working model with clear priory sets
Testing everyone is impossible, so creating a hierarchy of who does get tested and treated is vital
The government’s guidelines about how to contain the Covid-19 pandemic require considerable revision. They rely far too heavily on the strategy of testing as many people as possible (contact tracing), which has a limited yield and, given the shortages of coronavirus test kits and the processing backlogs in the labs, this approach will not help deal with this pandemic. We also don’t have the systems in place to reach people in remote areas.
So how should we change the guidelines to deal with the continuing exponential rise and expected spike in Covid-19 cases at a time when increasing numbers of people are returning to work? We need to stratify testing, with most-at-risk groups prioritised for testing. Broadly, the stratification should be in three priority groups, which can be further sub-grouped.
Priority A would have five sub-groups: group 1 should be people with chronic cardio-respiratory problems such as chronic obstructive pulmonary disease, including emphysema and chronic bronchitis; history of destructive lung TB; structural lung disease; chronic heart disease and hypertension; group 2 would be patients with diabetes mellitus, particularly with end-organ involvement; group 3 would be individuals on immune-suppressing treatment, whether for cancer, transplants or immune disorders; group 4 would be people over 60; and group 5 would be HIV-positive patients who are at high risk, in other words those with a CD4 count below 350 and an unsuppressed viral load.
Priority B would be all workers in healthcare facilities, including clinics, hospitals, frail care centres and old age homes. Priority C would be all people who are not in the first two priority groups, and this would be the low-risk category.
There is no problem with people returning to work and society returning to normal if everyone is committed to observing safety measures
If anyone in any of the priority A groups experiences symptoms or has been exposed to someone who has tested positive for Covid-19, they must immediately get tested and either quarantine or isolate.
Priority B group needs to be tested immediately if symptomatic or exposed to a Covid-19-positive individual, to avoid the risk of transmitting the coronavirus in the workplace. Subsequent management steps would depend on proximity of the worker to the positive individual, use of personal protective equipment (PPE) at time of exposure, and test results.
If you are in priority C group and you are asymptomatic, keep to the basic measures of avoiding spreading the virus and, if symptomatic but not requiring hospital admission, isolate. If symptomatic and needing hospitalisation, get tested immediately and isolate in that situation.
Irrespective of the priority category one falls into, every citizen needs to be vigilant about observing the well-established safety and hygiene measures at all times, both at work and at home. Under the proposed new guidelines, if, for example, you are not in a priority group A or B, and someone in your workplace contracts Covid-19 and you were observing all the safety measures and wearing PPE where necessary, do you need to be immediately tested and isolated for seven days to two weeks?
No, but you need to be vigilant about whether you are experiencing any early Covid-19 symptoms, such as a dry cough and shortness of breath, in which case you must immediately isolate.
Vigilant about hygiene
Immediately testing a contact who is asymptomatic has a high chance of yielding a negative result during the incubation period of the infection. Should an individual be symptomatic then, as stated above, they should isolate and be treated as having Covid-19 but only get tested if they are admitted for hospitalisation.
Regarding isolating those who come into contact with a person with Covid-19, the Western Cape has produced new guidelines that suggest you do not need to be isolated for seven days to two weeks. This differs from province to province. The Eastern Cape still stipulates that all those who come into contact with a person who has contracted Covid-19 must be isolated for 14 days.
We are hoping this will change. We want to emphasise that as long as preventive measures for Covid-19 are applied, the spread will be contained.
Most importantly, though, we have to educate the entire population that testing is only part of the fight. First and foremost, every citizen has to guard against contracting Covid-19 by treating every person encountered as a potential carrier. This is key and it applies as much at home as it does at work or in society at large.
If seeing your best friend for the first time in weeks, who you love, you still need to maintain the safe distance of 1.5m in any situation; wear your mask; sanitise and wash your hands. Good old soap and water works very well, and everybody needs to be aware of what they touch at all times, including notes or coins, ATM cards or keys. Sanitise and wash your hands regularly, and sanitise all your gadgets too, such as your cellphone, computer and keys.
We all need to get into the habit of being vigilantly hygiene aware. This is the most powerful defence we can all exercise, not only to protect against Covid-19 but also for protection from other diseasesm such as TB.
There is no problem with people returning to work and society returning to normal if everyone is committed to observing safety measures, including the use of PPE. It is proving futile to keep people at home in congested circumstances where they can easily infect each other if they do not practise protective habits at all times. What we are not seeing is enough education about this.
Nor are we seeing strong executive management of all the systems that need to work together to fight the pandemic, including the management of the quarantine and isolation sites. Any guideline changes at a provincial or national level will only be as effective as their executive management, and thorough and continuous education of all our people.
In summary, Covid-19 testing must be reserved for individuals that are a) high risk and symptomatic (priority A and B); and b) low risk, symptomatic and require hospitalisation (priority C).
• Prof Pepeta, a paediatric cardiologist, is executive dean of the health sciences faculty at Nelson Mandela University; Prof Nomvete, a gastroenterologist, is medical programme director at the university’s medical school.