Effect of a mobile laboratory deployment during the COVID-19 pandemic response, Adjumani District, Uganda, 2020-2021

Summary

Background: COVID-19 is a highly contagious and rapidly spreading disease, declared as a pandemic by World Health Organization (WHO) in 2019, was first reported in Uganda on March 21, 2020. At the start of the pandemic, COVID-19 testing in Uganda was centralized leading to long turnaround time. The rapid spread of the pandemic necessitated innovative strategies for effective testing and containment. The urgency to deploy mobile laboratories arose from the need to address challenges in turnaround time, test coverage in high-risk settings such as points of entry, crowded areas, and border regions. Adjumani District, a district centrally located in the Northern and West Nile regions of Uganda was one of the locations where a mobile laboratory for COVID-19 testing was deployed. The laboratory conducted real-time reverse transcription polymerase chain reaction (RT-PCR) testing, a standard molecular method for diagnosis of COVID-19 and served 32 districts in the Northern and West Nile regions of Uganda. We assessed the effect of a mobile laboratory on the test coverage, distribution, and average results turnaround time   in the Northern and West Nile regions of Uganda, 2020-2021.

Method: In this retrospective study, we analyzed data abstracted from the Results Dispatch System (RDS) for COVID-19 tests conducted in Northern and West Nile regions of Uganda between March 2020 to March 2021. This period covers before and after the deployment of the mobile laboratory. We used the Chi-square test of independence to assess the association between the test coverage and distribution and the mobile lab introduction in Adjumani; and the two-sample t-test to compare the mean turnaround time of results, before and after the mobile laboratory deployment.

Results: The Average turnaround time reduced from 40.27 hours to 21.93 hours, a reduction of 18.33 hours ((95% CI −19.16934, −17.49866) with results returned within 24 hours increasing from 11% to 88.9%, and those taking over 96 hours dropping from 100% to 0%. The overall proportion of suspected samples tested in the regions increased from 14.2% (852/6000) to 16.9% (972/6000) (p-value = ˂0.001) with testing coverage increasing in home-based care from 123/644 (19.1%) to 520/644 (80.9%), in prisons from 10/123 (8.1%) to 110/123(91.9%), in refugee camps from 41/372 (11.0%) to 330/372 (89.0%), and in quarantine centers from 32/538 (43.1%) to 306/538 (56.9%) (p-value = ˂0.001) .

Conclusion The mobile laboratory significantly improved the results turnaround time and coverage of COVID-19 testing in Northern and West Nile regions. The improved turnaround time facilitated quicker diagnosis.

Background

COVID-19 also referred to as SARS-CoV-2 is highly contagious, spreads rapidly and continuously evolves in the human population (1). Uganda reported her first COVID-19 case on March 21^st 2020, a Ugandan traveler returning from Dubai (2).

At the start of the pandemic, all samples for COVID-19 testing were centrally analyzed at Uganda Virus Research Institute (UVRI) in Entebbe and later on decentralized to Central Public Health Laboratories (CPHL) at the National Health Laboratory and Diagnostic Services (NHLDS) at Butabika and Makerere University College of Health Sciences Laboratory at Mulago. Despite the decentralization, turnaround time for COVID 19 test was approximately ≥72 hours(3), thus contributing to delay in patient management and public health intervention. Two negative Real Time- PCR results on sequential samples taken 24 hours apart and clinical recovery were required for patients to meet the criteria for discharge from a healthcare facility or isolation center at the time(4).

In order to address long turnaround time, Ministry of Health deployed mobile laboratories in designated areas such as points of entry targeting trucker drivers as a core group and districts with high number of cases(5). Mobile laboratories were deployed at Tororo General Hospital (serving Malaba and Busia POE in the Eastern part of Uganda) and Adjumani General Hospital which was serving 32 districts in the Northern and West Nile regions of Uganda including Elegu POE. These laboratories conducted real-time reverse transcription polymerase chain reaction (RT-PCR) testing, a standard molecular method for diagnosis of COVID-19(6). Before deployment, samples from Northern and West Nile regions were tested at the Central Public Health Laboratories and Uganda Virus Research Institute. After deployment, testing of these samples was fully at the mobile laboratory in Adjumani District starting September 2020.

We assessed the effect of a mobile laboratory on the test coverage, distribution, and average results turnaround time in the Northern and West Nile regions of Uganda, 2020-2021.

Methods

We conducted a retrospective study using COVID-19 testing data abstracted from the Results Dispatch System (RDS), (March to August 2020) before the Adjumani Mobile laboratory deployment and (September, 2020 to March 2021) after the deployment was analyzed.

We abstracted data regarding patient information such as age, gender, nationality, date of sample collection, sampling site, result, result date and sample type while the dependent variable was the proportion of suspected samples tested before and after the mobile laboratory deployment. All data was extracted from the National COVID-19 Results Dispatch System (RDS) into excel sheets for the study period (March 2020 to 31^st March 2021).

We checked for significance differences between test coverage before and after mobile laboratory deployment using the Chi-square test of independence. To compare the mean turnaround time of test results (time from specimen collection to results release) the independent t- test was used to compare the mean turnaround time before and after the deployment of the mobile laboratory.

Data was extracted from the National COVID-19 Results Dispatch System (RDS) and no personal identifiers included. Permission was sought from the National Health Laboratory and Diagnostic Services, Ministry of Health (NHLDS- MoH) to access and use the data.

Results

Test coverage and distribution before and after mobile laboratory deployment, Northern and West Nile regions, Uganda, March 2020-March 2021

There were significant differences in the numbers tested from the different sampling sites with more samples having been tested at the different sites after the mobile laboratory deployment (p<0.001) (Table 1).

Most of the results were released with medium turnaround time 2,922 (48.7%) (24-48 hours) followed by shortest turnaround time 2,545 (42.4%) (>24-hours) with the minority of the results being released beyond 96 hours 19 (0.3%). Furthermore, majority of the test results in the mobile laboratory were released in less than 24 hours 2,262 (88.9%) and no result released beyond 96 hours compared to before the mobile laboratory deployment where majority of the results were released between 24 hours and 48 hours 2,224 (76.1%) (p <0.001) (Table 1).

Table 1:  Test coverage and distribution before and after mobile laboratory deployment in Northern and West Nile regions, Uganda, March 2020-March 2021

Characteristic	Total			P-value
	N = 6000	Before Mobile lab, N= 3000 (%)	Mobile Lab, N= 3000 (%)
Gender
Female	1,212 (20.2)	336 (27.7)	876 (72.3)	<0.001
Male	4,788 (79.8)	2,664 (55.6)	2,124 (44.4)
Age group
0-18 (Children)	667 (11.1)	348 (52.2)	319 (47.8)
19-35 (Youth)	2,735 (45.6)	1,368 (50.1)	1,367 (49.9)	<0.001
36-64(Middle-age adults)	2,507 (41.8)	1,259 (50.2)	1,248 (49.8)
≥65(Elderly)	91 (1.5)	25 (27.5)	66 (72.5)
Result
Positive	564 (9.4)	325 (57.6)	239 (42.4)	<0.001
Negative	5,436 (90.6)	2,675 (49.2)	2,761 (50.8)
Sampling sites
Health facility	1,214 (20.2)	713 (58.7)	501 (41.3)
Home based care	644 (10.7)	123 (19.1)	521 (80.9)	<0.001
Point of Entry	3,109 (51.8)	1,881 (60.5)	1,228 (39.5)
Prisons	123 (2.1)	10 (8.1)	113 (91.9)
Quarantine centers	538 (9.0)	232 (43.1)	306 (56.9)
Refugee camps	372 (6.2)	41 (11.0)	331 (89.0)
Nationality
Ugandan	3,575 (59.6)	1,308 (36.6)	2,267 (63.4)
South Sudanese	436 (7.3)	31 (7.1)	405 (92.9)	<0.001
Kenyan	311 (5.2)	209 (67.2)	102 (32.8)
Other EAC country	28 (0.5)	18 (64.3)	10 (35.7)
Others	1,650 (27.5)	1,434 (86.9)	216 (13.1)
Turn Around Time (Hours)
< 24 (Shortest)	2,545 (42.4)	283 (11.1)	2,262 (88.9)	<0.001
24 – 48 (Medium)	2,922 (48.7)	2,224 (76.1)	698 (23.9)
49- 96 (Long)	514 (8.6)	474 (92.2)	40 (7.8)
>96 (Longest)	19 (0.3)	19 (100.0)	0

Average turnaround time of COVID-19 test results before and after mobile laboratory deployment, Northern and West Nile regions, Uganda, March 2020-March 2021

The mean turnaround time before Adjumani mobile laboratory was 40.269 hours and 21.935 hours after deployment of Adjumani mobile laboratory. The difference in the mean turnaround time was 18.334 hours and this was statistically significant (95% CI =−19.2, −17.5) (Table 2).

Table 2: Turnaround time before and after mobile laboratory deployment, Northern and West Nile regions, Uganda, March 2020-March 2021

Group	Observations (Obs)	Mean	Std. Err.	Std. Dev.	[95% Conf. Interval]
Combined	6,000	31.102	0.243709	18.87761	30.6, 31.6
Before Mobile lab	3,000	40.269	0.393685	21.56302	39.5, 41.0
After Mobile lab	3,000	21.935	0.163054	8.93081	21.6, 22.3
Difference		18.334	0.426115		-19.2, -17.5

Discussion

The deployment of the mobile laboratory resulted in a substantial reduction in turnaround time for test results. Prior to deployment, most test results were released within 24 to 48 hours, whereas post-deployment, most of the results were available within 24 hours, with none exceeding 96 hours. This was crucial for timely decision-making like quicker isolation and treatment of positive cases, thereby minimizing transmission risk. There was also improved test coverage and distribution of tests across various sampling sites. There was a substantial increase in the number of tests conducted in prisons, refugee camps, home-based care settings, and quarantine centers. The mobile laboratory deployment enabled COVID-19 testing in underserved and high-risk populations, ensuring that more individuals are tested, facilitating early detection and isolation of positive cases to curb the spread of the virus.

Before deployment of Adjumani Mobile laboratory, COVID-19 samples collected from Northern, West- Nile regions and points of entry were transported to UVRI for PCR testing resulting in significant delay in turn-around-time. After deployment of Adjumani mobile lab, there was a statistically significant reduction in turn-around-time and this led to improved management of COVID-19 patients in the region (7). Quick diagnosis is key in disease containment, improves the effectiveness of treatment and helps to avoid long-term complications for the infected patients.  This  was evident in South Korea where the rapid of test capacity with a turnaround time of 6 to 24 hours in core and risk populations meant that cases were identified early, isolated and case-based contact tracing quickly initiated across large clusters of cases contributed to the containment of the epidemic in the country (8).

Since it is recognized that nearly half of the COVID-19 infections are transmitted by asymptomatic cases it was important to test as many people as possible especially contacts, people in quarantine centers, refugee camps and prisons (9). Testing of large population for COVID-19 including asymptomatic cases helped to prevent the spread of COVID-19 by identifying people who needed care in a timely fashion. A positive test in the early course of the disease enabled individuals to isolate thus reducing the chances of infecting others and also to access treatment early, reducing the likelihood of disease severity and the risk of long-term disability or even death.

Study limitations

The key limitations of the study were its retrospective design, which relied on potentially incomplete or inaccurate historical data, and inconsistencies in the National COVID-19 Results Dispatch System that could compromise the accuracy of test coverage and turnaround times. To mitigate these limitations, we audited the RDS for errors and cross-verified historical data with alternative primary data sources. While the mitigation efforts improved the quality of the data, complete resolution was not achieved, limiting the accuracy in calculating the test coverage and test turnaround time.

Conclusion

The Adjumani mobile laboratory significantly improved the results turnaround time and coverage of COVID-19 testing in Northern and West Nile regions. The improved turnaround time facilitated quicker diagnosis.

Recommendations

Integration of mobile laboratories into the national health laboratory systems would greatly improve outbreak response with reduced result turnaround time which is crucial for public health interventions.

Conflict of interest

The authors declare no conflict of interest.

Authors contribution

RN: participated in the conception, design, analysis, interpretation of the study and wrote the draft bulletin; SG, PG, MP, KB, MT, MO, MRE, GA, RN, IM, GN, AW, NR, IS, AK and SN reviewed the report, reviewed the drafts of the bulletin for intellectual content and made multiple edits to the draft bulletin; RN, SG, and ARA reviewed the final bulletin to ensure intellectual content and scientific integrity. All authors read and approved the final bulletin.

Acknowledgements

We thank the ministry of health for permitting us to respond to this outbreak. We thank the East African Community Mobile Laboratory project and Bernhard-Nocht-Institute for Tropical Medicine for the donation of the mobile laboratories.

Copyright and licensing

Copyright and licensing

All material in the Uganda Public Health Bulletin is in the public domain and may be used and reprinted without permission. However, citation as to source is appreciated. Any article can be reprinted or published. If cited a reprint, it should be in the original form.

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