Impact of turnaround time in delivery of Covid-19 results and surveillance: a case of points of entry, Uganda

Joyce Owens Kobusingye¹, Mitima Jean-Marie Limenyande^1,&, Harriet Mayinja²

 

¹School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda, ²Department of Integrated Epidemiology Surveillance and Public Health Emergencies, Points of Entry, Ministry of Health - Uganda

 

 

^&Corresponding author
Mitima Jean-Marie Limenyande, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda. mitimalim@gmail.com

 

 

 

 

Turnaround time (TAT) is a major factor that allows the assessment of performance for all the services offered in a laboratory [1,2]. A shorter TAT increases satisfaction to both the patient, the clinician and the laboratory personnel at a point. On the clinician´s side, satisfaction is geared more at having a basis on which he can give treatment and make informed decisions [3,4] regarding a patient´s health or a health event. To the laboratory personnel, focus is more on meeting the expectations of clients - the patient´s and the clinician [3]. The definition of TAT has itself been a source of disagreement among laboratory workers and clinicians: At what point do we account for turnaround time and to what end? Despite the different views, the consensus is that laboratory TAT covers three major phases; the pre-analytic phase; that starts when the examination is ordered to preparing the sample in the laboratory, the analytic phase; when tests are performed in the laboratory and the post-analytic phase; when results are reported back so action or a decision is made [1-3].

 

Shortening the laboratory TAT has for long been a goal in health care provision [5] and many have invested a lot of resources to achieve this. It ought to be understood that, people in health emergency and health practitioners in outbreak responses need results fast during any intervention. This concern arises out of the need to save lives and thereafter offer treatment [6,7]. The improvements made around TAT have been aimed at shortening the time along the different paths - from picking the samples to availing of results. Distance from the sample collection point to the laboratory is another vital factor [4,8,9]. But the use of mobile laboratory in field responses ensures that results are provided in the shortest time possible [3,10]. Field teams can now use mobile polymerase chain reaction (PCR) equipment, to allow for access of results as fast as - less than half an hour [8,11]. The number of samples received from different sample collection points in an area and the priority given to them at the laboratory also plays a key role in determining the TAT. Timely communication between healthcare workers and the laboratory professionals is vital in ensuring mutual understanding and collaboration after the samples have been collected and delivered at the laboratory. This may include informing the healthcare workers about potential reasons for delayed results; system breakdown, workload and certain test menu limitations so they inform the travelers waiting for results in time [12]. The ideal situation to reduce TAT would be to bring the laboratory services closer to the sample collection points. With the COVID-19 pandemic, the increase in demand of laboratory services has created longer TAT and shortage of supplies used in sample collection [13].

 

In the context of COVID-19 pandemic, the turnaround time for results can increase the risk of transmission of the virus from those waiting for results –who may be asymptomatic– to more susceptible people [14, 15]. In Uganda for example, as the truck drivers waited in long queues for their results at the different POE, the longer they continued to interact with the communities the higher was the risk of exposing them to the virus and thus the increase in the number of cases at border points [16]. At the start of COVID-19 pandemic in Uganda in 2020, the Ministry of Health (MOH) implemented strict border control measures at an early stage of the pandemic to reduce transmission. All POE connecting Uganda to neighboring countries were closed, with minimum restrictions to truck drivers to keep economic environment vibrant [17].

 

To facilitate smooth operation, the Eastern Africa Community (EAC) Secretariat and its Partner States rolled out the Regional Electronic Cargo and Drivers Tracking System (RECDTS) to enable the issuance of the EAC COVID-19 digital certificates recognized by Partner States to ease movement across the border. Despite its reliability, there are notable challenges regarding its effectiveness in providing timely certificates to truck drivers; requiring one to have a smartphone or its equivalent and being connected to internet to access the negative results [18]. The TAT in sample collection, transportation to laboratory and the ability to access results plays an important role in facilitating surveillance especially now in the fight against the COVID-19 pandemic. This study therefore aimed at assessing the factors determining turnaround time in sample collection, estimate the turnaround time of delivery of COVID-19 test results at different POE and its impact on surveillance in Uganda.

 

 

Study setting

 

The short study was carried out at the Emergency Operation Center (EOC) field site in Kampala district with a few field visits at the different POE from August 2020 to December 2020. The EOC is a co-ordination center for all emergency related responses: COVID-19, Measles, Tuberculosis, Anthrax, Cholera and EVD, with COVID-19 response at the helm of it at the moment - 2020. POE surveillance is a sub-pillar under the surveillance pillar and reports on 58 operational POE around Uganda during the COVID-19 pandemic, including Entebbe international airport.

 

Study participants

 

The study participants were thirty-three (33) POE contact persons who were purposively selected because they worked at these respective points and had key information regarding POE operations on the ground during the COVID-19 pandemic. We also engaged five (5) key informants who were POE officers at the EOC in charge of different regions where the POE are located and are charged with reporting during the surveillance committee meetings Table 1.

 

Study design

 

We conducted a cross-sectional study where we used both quantitative and qualitative methods. Participants were subjected to a set of both structured and semi-structured questionnaires during the interviews. We also carried out a secondary data analysis of the POE situation reports submitted at the EOC during surveillance committee meeting every Monday, Wednesday and Friday.

 

Sampling procedure

 

We ranked the POE according to the number of travelers screened at their border points in four months (May to August 2020). The first twenty POE had registered over 75 percent of the total travelers that crossed border points during the period were all included in our sample. Also, all the positive cases recorded from border points since the start of the epidemic in the country; were identified from those POE. Among the 20 POE, 7 were from the Western region, 5 from the northern, 3 from the central 5 in the Eastern. We conveniently selected 13 more POE–following the ranking we used –to ensure we have a perspective from the POE with fewer travellers.

 

Study variables

 

The dependent variable in the study was turnaround time of sample collection and delivery of COVID-19 test results. The independent variables were; location of POE, number of samples collected, transportation used to take the sample to the laboratory, infrastructure for isolation and quarantine of people waiting for results, number of sample collection points, functionality of sample tracking systems, interval of sample collection, number of testing centers, volume of people at site, availability of sample collectors, and availability of funds to pay for the test by travelers.

 

Data collection methods

 

Interviews were conducted via phone calls for staff at POE sites and face to face for key informants at the EOC. We used a set of structured and semi-structured questionnaires with 13 questions to answer our study objectives. All respondents were called within two weeks, from 12th October 2020 to 25th October 2020, and each phone call lasted approximately 15 to 20 minutes on average. Information was also obtained from key informants to check for consistency of responses obtain from the staff at POE sites.

 

Data management and analysis

 

Information from each POE was kept separately in a book. After verification of the information from key informants, the data from open questions was coded and analyzed manually. The codes were grouped into categories and the emerging themes were then identified from the records and given an overall meaning.

 

A different approach was used for the close-ended questions. For questions answered by yes or no we summarized using count and percentage. For age and the turnaround time for covid-19 results, we summarized using mean, median and standard deviation. The whole analysis was done using Microsoft Excel 2016– it was also used to generate the summary table.

 

Ethical consideration

 

This study was approved by Makerere University School of Public Health. Consent was sought from respondents and the POE overall focal person at the EOC, and later the respondents were also informed prior of the impeding interview before the interviews were made.

 

 

Availability of testing laboratory and laboratory personnel

 

Our assessment found that out of the 33 POE contacted, majority (30 POE) had a laboratory personnel onsite to collect samples from travelers Table 2. Usually, the laboratory technician transported the samples collected to the laboratory located either within the district or outside of it.

 

Regarding the number of laboratories in the district, we noted that MOH increased the number of laboratories in the districts and regions - including mobile laboratory to meet the demand for testing in different regions. Those that didn´t have testing laboratory or if the nearest laboratory had many samples waiting to be tested or had a technical issue; samples were taken to other laboratories in the region or in Kampala. The complexity of this path was increasing the turnaround time for results but also created more risk in damaging the samples due to longer travels.

 

We noted also that provision of services offered by the laboratory personnel was affected by several events apart from breakdown of some of the mobile laboratories installed. When the number of travelers increased— due to easing of the travel ban and movement in the country, the situation at the POE worsened as the number of samples to be tested increased. Some of the POE did not have permanent shelters and were subject to natural conditions like heavy rain or were destroyed due to aging and needed to be replaced several times throughout the epidemic. That led to failure to meet the sample collection requirement that affected the COVID-19 response at those specific POE.

 

COVID-19 supplies

 

During the interviews, the POE focal personnel revealed that they didn´t experience stock out of COVID-19 supplies. Those that did, got in touch with the responsible personnel at the district or central office at the MOH and were restocked within a shortest period Table 2. However, not all the required supplies were available and in sufficient number whereby some of the PPEs were sometime not available. Despite that fact, laboratory technicians had to adapt to those difficulties to keep the flow of activities.

 

Transport means used at POE

 

Twenty-seven POE out of 33 used vehicles to deliver the samples collected from the POE to the laboratory Table 2. Sometimes, the vehicle was given for a short period by a partner supporting the POE during Covid-19 pandemic. The other means of transportation was motorcycle and public means, reported respectively by 4 and 2 POE; but this risked the samples being damaged due to poor storage and nature of bad roads at some POE. In addition, at some sites, the collected samples did not go through a straight path; meaning from the POE where the sample was collected to the laboratory where the test will be performed. This situation was frequent for POE without a laboratory within the same district thus the samples from different locations including POE, were gathered to another sample collection point (like a health facility) and form there, a common means of transport was used to take the samples to the laboratory located miles away. That was done mostly once in a day and in the evening; after all the samples collected during the day have reached the health facility used as collection point.

 

Public transportation was used in rare and particular situations. The situations occurred when the provided means of transport had broken-down while an important number of travelers were waiting for their COVID-19 results.

 

Average waiting time for results

 

After the long path of samples, results could be accessed online by the POE staff. The median waiting time was three days with at least one day and maximum of seven days. Outlier situations were reported by few POE which had to wait up to seven (7) days Table 2. Several reasons contributed to this difference in turnaround time as discussed herein. For those outlier situations, among the explanations were the POE focal people forgetting to print results for the system.

 

Ability to access results from the Result Dispatch System (RDS) dashboard

 

Although results were uploaded on the COVID-19 online RDS developed specifically for quick access to results, some support staff could not access the dashboard. Majority reported the lack of internet at the POE site and/or electricity to power the gadgets they were using Table 2. For those who didn´t have electronic gadgets, they had to wait for other persons to either send them the printed hard copies of the results or the soft copies were sent through another assigned person.

 

Willingness to pay for a COVID-19 test

 

The payment for the test was implemented to ease on the high expenses that the government was incurring to support the national response. Truck drivers were ready and willing to pay for the COVID-19 tests because they needed the COVID-19 certificate so they can deliver their goods to the final destinations Table 2. Other travelers would either not afford to pay for the test or found it expensive and would request that the price is reduced. Those who were not willing to pay—especially the border communities argued that they have relatives across the border and couldn´t be subjected to daily testing if they had to visit them.

 

Implementing the RECDTS eased the testing workload at the POE and facilitated access to results for truck drivers. Operations at the different borders using the system were improved. Drivers had the option to pay and do the test before reaching the border, from any testing site in the country where they come from. The limitation to this was the lack of smart mobile phones by some drivers. The personal result had to be uploaded on an electronic gadget like a smart-phone and its validity would then be verify at every check point along the different POE.

 

Impact of long turnaround time for results on COVID-19 activity at POE

 

Most of the POE did not have an isolation or quarantine facilities. They did not have a waiting area to accommodate the huge number of travelers waiting for results. Majority of the POE staff required travelers to wait for their results from either the trucks or go back home. Finding contacts of these travelers if results turn out to be positive was through contact tracing. However, the practicability of this approach was not straight forward; some contacts of cases were not willing to cooperate due to fear and stigma around COVID-19. The list of contacts could sometime not be listed exhaustively as many days have passed since the test was requested. When cases soared, logistic issues came on board as people to be evacuated became many while the process required more personnel. Besides management challenges with risk of spreading the diseases while waiting for results; travelers had to wait for days before having their results that contributed to delays in transportation of goods. Clearly, the long turnaround time had negative impact on POE - poor performance regarding the management of suspected cases of COVID-19 due to delay of decision making.

 

 

The turnaround time for results was generally longer at POE, which is the same situation that happened elsewhere as the number of COVID-19 cases increased [7]. Throughout the epidemic countries worked hard to reduce the turnaround time for results; up to less than 24hr for many and this was achieved through better testing approaches and use of mobile laboratories to eliminate transportation of samples to distant places [4,9,19]. With Uganda, the samples collected from the POE were sent to other districts miles away where the laboratories were not in the district. MOH therefore increased the number of laboratories that could perform the tests in the different regions although the facilitating supplies could not meet the demand given the soaring number of cases.

 

The lack of medical supplies noticed at the POE was a general trend noticed globally and the high demand for medical supplies from medical facilities and public health implementing partners could equally not be met by manufacturing industries [20,21]. Even though there was lack, health workers at the POE had to adjust to the situation; laboratory technicians had to work without or repeatedly used the same protective equipment´s which increased the risk to getting infected with COVID-19.

 

The role of electronic software has also proved to be of relevance in reducing the turnaround time for results during the COVID-19 pandemic because different people accessed their results occasionally [22] and for Uganda the RDS played this key role. However, there were a few challenges on the user´s side; lack of battery power and gadgets to access the results. The approach used in Taiwan [23] went far by tracking infected persons via their electronic devices and the same approach was is used in the EAC region for truck drivers - RECDTS.

 

The noted impact of long turnaround time was the delay in decision making at the POE, for stakeholders and reporting which generally hindered surveillance during the outbreak [6,14]. The longer the time to dispatch samples and deliver results, the more challenges in the operations of POE activities especially regarding handling travelers who were probable cases. This resulted into community transmissions because travelers continued to associate with the local population in the area as they waited for their results

 

Study Limitations

 

This study analyzed turnaround time using POE focal person judgment. Also, it did not include the laboratory component to assess the analytical process of samples delivered. An analysis tracking samples from the point of collection at the POE, throughout their journey - including the laboratory - until results are released, would also give a good insight on the other factors affecting the turnaround time for COVID-19 results.

 

 

The COVID-19 pandemic has created a public health crisis that can be mitigated only with implementation of programs designed specifically to address the needs that arise occasionally given the high rate of community transmissions right. We therefore conclude that surveillance should prioritize accessibility of testing facilities, minimize sample-to-answer time; analytical limits test results and train staff on administrative activities that need to be carried out on site to manage any related outbreak.

 

 

The authors declare no competing interests

 

Disclosure

 

The findings in this report are those of the authors.

 

 

Joyce Owens Kobusingye and Mitima Jean-Marie Limenyande: Conception and design, acquisition of data, analysis and interpretation of data, drafting the paper, revising the manuscript for important intellectual content and final approval of the version to be published. Harriet Mayinja: Acquisition of data, revising the manuscript critically for important intellectual content and final approval of the version to be published. All authors read and approved the final version of the manuscript.

 

 

Table 1: Socio-Demographic Characteristic of respondents and Location of POE

Table 2: Summary analysis of key findings

 

 

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