Testing delays worsen, hurting efforts to control COVID-19 spread in Canada

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Multiple health regions across the country are missing target turnaround times for COVID-19 test results, hampering efforts to keep the spread of the virus under control.

While experts say the goal should be to complete COVID-19 tests within 24 hours, some of the worst hot spots are taking three days or more. In Winnipeg, for example, less than 2 per cent of tests were turned around in under 24 hours, and less than 20 per cent were done in under 48 hours.

Amid the start of a second wave, which is coinciding with the beginning of cold and flu season, testing delays are worsening in various regions, owing to limited lab equipment, space, testing materials and a shortage of personnel.

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“Ideally, it should be within 24 hours. [Anything beyond that], it just doesn’t make public-health sense,” says Annelies Wilder-Smith, a professor of emerging infectious disease at the London School of Hygiene and Tropical Medicine in England.

Delays in testing not only hinder contract-tracing efforts, they also could result in more people being exposed to the virus while infected individuals await their results, says Michael Libman, a professor of medicine at McGill University’s division of infectious diseases.

In British Columbia, the average seven-day turnaround time for test results was 42.3 hours. In Ontario’s Simcoe Muskoka District Health Unit, the most recent estimate for the average turnaround time was 2.6 days. (Turnaround time is defined as the time period between when a person provides a laboratory specimen for COVID-19 testing to when a positive result is reported to a public-health unit.)

In Toronto, a seven-day average of 28 per cent were turned around within 24 hours, and 64 per cent of tests were turned around within 48 hours – well short of the provincial goal of having at least 60 per cent completed within 24 hours and 80 per cent completed within 48 hours. In the Quebec City health region, 94 per cent of laboratory analyses are completed and transmitted between 48 to 72 hours. In Alberta, just 23 per cent of tests were turned around in 24 hours over the past seven days.

Jason Kindrachuk, an assistant professor in the department of medical microbiology and infectious diseases at the University of Manitoba, says a recent spike in the number of cases in that province comes just as labs are “behind the eight ball” on processing test results. Manitoba recorded 173 new cases on Thursday, the third day in a row the province set a new record.

As the number of cases began surging in Ontario and Quebec during the second wave, it was only a matter of time before the virus spread to the West, Dr. Kindrachuk says. “Most of us who work in infectious diseases have seen the writing on the wall."

There are multiple factors causing bottlenecks and contributing to backlogs, says Dr. Libman at McGill in Montreal. The sheer number of tests that need be processed is unprecedented, and increasing a laboratory’s ability to process more tests cannot be accomplished easily, he says. It requires the addition of a lot of trained staff, expensive machinery and high-tech equipment.

Many provinces are now processing roughly 10 times the number of tests they did in March or April. Ontario, for instance, has increased its COVID-19 testing capacity from 4,000 to more than 40,000 tests daily within the past six months, according to Ontario Health.

There are obstacles at almost every step of the testing process – the first of which is determining who should be tested, says Dr. Libman. As jurisdictions have tried to make tests widely accessible, the result is that many people who are getting tested probably do not need to be tested, he says.

In Ontario, instead of using resources by testing everyone who wanted one during the summer, including asymptomatic individuals at an estimated cost of $100 a test, the province should have invested in developing testing infrastructure to cope with the expected rise in demand this fall, says Zain Chagla, an associate professor in the division of infectious diseases at McMaster University in Hamilton.

Another obstacle many labs and testing centres face is a lack of personnel to do all the clerical work. With testing centres collecting many thousands of specimens with paper requisition forms, “somebody’s got to enter all that stuff, and it seems very non-technical,” but this can be a massive bottleneck, Dr. Libman says.

Another widespread problem is ensuring labs have enough swabs, test tubes, reagents and all the materials needed to do the tests. Most of these materials are imported, and there is global competition to procure them.

Jeffrey Dale, chief executive officer of the non-profit Eastern Ontario Regional Laboratory Association, whose hospital labs serve the Champlain area, including Ottawa, says his organization is working to increase its COVID-19 testing capacity from about 3,500 a day currently to 6,000 a day by the end of this fall, a goal set by the Ontario Ministry of Health.

One of the major challenges is to recruit and train staff to do the labour-intensive work of preparing, registering, processing and storing samples. That means expanding its current team of about 55 people to roughly 90. Retaining staff is also no easy feat, Mr. Dale says.

“These individuals are working incredible hours, under an incredible amount of stress,” he says.

Given these constraints on increasing testing capacity, Dr. Chagla says changes to the current COVID-19 testing strategy are urgently needed to make testing more manageable and ensure it is useful for controlling the spread of the virus.

He suggests the top priority should be to ensure everyone who is symptomatic has easy access to a test, and can receive a result within 24 hours. If a test is positive, public-health officials should then aggressively conduct contact tracing.

“That from a public-health standpoint is going to be our biggest tool to really get outbreaks under control,” he says.

After that goal is reached, public-health authorities can then consider testing in other scenarios, such as testing asymptomatic individuals who have been exposed to someone with COVID-19, he says.

Rapid test devices, which are less sensitive but also less expensive and take less time, could be used for routine surveillance testing of asymptomatic individuals in vulnerable populations, such as in long-term care homes, he suggests.

Some labs have already managed to become more efficient. Larissa Matukas, head of the division of microbiology at St. Michael’s Hospital at Unity Health Toronto, says her lab, which handles more than 1,000 specimens a day from multiple sites, has been surpassing the provincial goal for testing turnaround times by completing 100 per cent of new COVID-19 tests within 48 hours. Seventy per cent of them are done within 24 hours.

Transport couriers deliver specimens from each of the collection sites every hour or two to ensure a continuous flow. The lab is also open 24 hours, seven days a week.

The hospital also has infrastructure in place to ensure the transmission of information is seamless, from the site of collection to reporting the results and notifying patients, Dr. Matukas says. Patients are registered at assessment centres as though they are hospital patients, so all of their demographic details can automatically be accessed through the lab information system, she explains. To enter information from paper requisitions, the assessment centres also rely on drop-down menus with standardized entry options, such as whether the person is symptomatic or from a long-term care home.

“The more that you can automate, the better,” Dr. Matukas says, noting the goal is to ensure a continuous process, instead of a batched process, where specimens are only transported to the lab at a certain time of day and only processed between certain hours.

Since the beginning of the pandemic, experts have warned that having the IT infrastructure to be able to easily track and trace test samples would be critically important, she says.

“But the efforts toward resolving the IT issues has been slow,” she says. “I don’t know if that’s because there just hasn’t been resources for it or it got deprioritized.”

Dr. Matukas suggests changing the way labs within the same network co-ordinate an overflow of tests. Currently in Ontario, a lab that has more specimens than it can handle will send the rest to another. This can take hours or days to co-ordinate. Instead, she suggests, this co-ordination could be done at the level of the collection site, where specimens can be directed to the labs that have the capacity to handle them.

Without changing the current testing strategy, Canadians can simply expect one lockdown after another, Dr. Chagla at McMaster says, noting that the demand for testing is expected to be even higher in December and January than it is now, as more respiratory viruses begin to circulate during the winter months.

“If our test capacity is locked here, we’re going to be stuck for the time coming, for sure.”

With reports from Les Perreaux in Montreal

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