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Why re-testing Covid-19 patients is dicey debate

By People Reporter
Tuesday, June 30th, 2020
A Ministry of Health officer performs a mouth swab to a resident of Kawangware estate in Nairobi during a mass testing for Covid-19 in the area. Photo/PD/JOHN OCHIENG
In summary
    • Concern to medics is whether some of the patients being discharged from the facilities after a 14-day quarantine could still be positive and pose a risk to the public.
    • In the latest guidelines — for mild, very mild and pre-symptomatic cases admitted to a Covid-19 care facility — patients would undergo regular temperature and pulse monitoring.
    • For one to be sure they’re completely recovered the person should go for a test to confirm the same.

Medical practitioners are grappling with the question of whether Covid-19 patients in quarantine should be re-tested before being re-admitted into society, in the wake of the government’s decision to introduce home-based care.

The standard procedure is that anyone being put in quarantine is tested within the 14-day period, but because of lack of testing kits, they are released without re-testing if they don’t develop any symptoms within the quarantine period.

But a section of medical professionals are raising concern over the big number of asymptomatic Covid-19 patients being discharged from various isolation centres across the country without being re-tested to determine their status, saying this could drag the war on the virus.

Of major concern to medics is whether some of the patients being discharged from the facilities after a 14-day quarantine could still be positive and pose a risk to the public.

Last week, more than 1,000 patients who had been admitted to various health facilities were discharged either after completing the 14-day mandatory quarantine or after staying for 10 days without developing any symptoms.

Confirmed positive

So far, Kenya has 6,070 confirmed positive cases of coronavirus, out of which 90 per cent, translating to 5, 463 persons, have been asymptomatic with mild cases.

Interestingly, the government states that only 1, 971 people have so far recovered, based on individuals who have had the opportunity to be tested twice after being discharged.

The fate of about 2, 500 others who had tested positive, albeit without showing symptoms and were discharged without being rested, is left hanging in the balance.

Amidst doctors’ concerns, the government says the decision is pegged on the revised World Health Organisation (WHO) guidelines as well as lack of reagents and testing kits.

“This is part of the new guidelines that encourage home-based care instead of people being taken to isolation centres so that we reserve such facilities for moderate and severe cases.

Admitting all people who test positive is already straining both the government and the facilities,” says Health CAS Dr Mercy Mwangangi.

According to the latest guidelines — for mild, very mild and pre-symptomatic cases admitted to a Covid-19 care facility — patients would undergo regular temperature and pulse monitoring.

“Patients can be discharged after 10 days of symptom onset and if they have no fever for three days.

There will be no need for testing prior to discharge,” Dr Mwangangi said. She added that at the time of discharge, patients will be advised to follow the home isolation for seven more days.

Mwangangi says that the guidelines further clarify that after discharge from a facility, if patients develop symptoms of fever, cough or breathing difficulty, they must contact the Covid-19 Care Centre or State helpline or 1075.

Their health will again be followed up through tele-conference on Day 14. Moderate cases will undergo monitoring of body temperature and oxygen saturation.

“If fever resolves within three days and a patient maintains saturation above 95 per cent for the next four days (without oxygen support), he or she will be discharged after 10 days of onset of symptoms in case there is no fever without anti-fever drugs, no breathlessness and no need for oxygen,”  Mwangangi told People Daily.

But according to several medics, the new guidelines could be difficult to implement in Kenya where majority of the people hold stigma over Covid-19 and coupled shortage of personnel to make follow ups.

“We started off on a wrong footing by stigmatising everything about Covid-19. And the general view out there is that being infected is a death certificate.

Do we have enough health personnel to make a follow up on some of the people discharged?

Are our people ready to voluntarily report to health facilities once they develop such symptoms given the fact that nobody wants to be associated with anything to do with the disease?” a senior doctor at the Kenya University Teaching, Referral and Research Hospital’s Infectious Diseases Unit, who declined to be named due to the sensitivity of the matter, questioned.

Does being recovered according to the new guidelines mean a person is definitely no longer infectious? Does having Covid-19 once mean you have immunity to the disease? If so, for how long?

Apparently, recovered people don’t really know where they stand with the virus. Some are rattled, emotionally, psychologically, and face stigmatisation as they re-enter society.

The WHO guidelines feature two paths to recovery: One is when a person receives two negative Covid-19 tests at least 24 hours apart. 

Two, after an infected person spends at least 10 days without showing any symptoms, which is now being contested. For one to be sure they’re completely recovered the person should go for a test to confirm the same. 

Lack of reagents and testing kits have created room for booming business for private laboratories and hospitals that are charging an arm and a leg for tests.

Already, there is general fear among Kenyans to visit hospitals with government and independent statistics indicating a sharp decline in patient numbers.

But as every Kenyan knows already, it is not easy to get even one test, much less two.

And even as the testing has become complicated, many employers are making it mandatory for one to acquire a Covid-19 certificate to be allowed to work.

According to Dr Willis Akhwale, a Nairobi-based WHO consultant, the decision to send home Covid-19 asymptomatic patients without re-testing them could be a disaster in the making.

“People sent back untested may spread the virus in the community and that is why we need to establish enough testing facilities.

What is the purpose of isolating an individual in an isolation facility for 14 days given the fact that there is medication they are given, only to release them without re-testing?” Akhwale posed.

His observation is pegged on the fact that besides being provided with ordinary multi-vitamins tablets and mouth wash to boost their immunities and prevent infection, asymptomatic patients are simply herded into isolation facilities waiting to be fed without any treatment.

Akhwale proposes that government needs to come up with clear guidelines on the discharge of Covid-19 patients and their re-acceptance in society.

“I think we have several gaps in the management of the pandemic that needs to be put in place,” he says, adding that the gold standard for determining if a patient is no longer infectious would be a cell culture, in which an isolated virus would be placed in cells to see if it could still reproduce.

But that’s highly labour-intensive and expensive,  Dr Akhwale said. “There is no way — zero way — we can do viral cell culture at wide scale.” 

That leaves, for now, polymerase chain reaction (PCR) tests, which are capable of detecting tiny traces of the coronavirus.

The presence of a minute scrap of coronavirus genetic material can register as a “positive” result even if the patient is no longer infectious.

The presence of virus particles does not necessarily mean that the virus is still viable.

Amid these uncertainties, Covid-19 patients may lack confidence they’ve left the virus behind.

“People are sending mixed signals when you are allowed to leave quarantine,” said Sylvester Otieno, who tested positive for coronavirus last month and was forced to stay in a government facility for two weeks before being discharged without being re-tested.

Conflicting guidance

Otieno says he has been given conflicting guidance on when it is safe to interact with others.

One doctor told him he didn’t know. Another told him 14 days from the date of his positive test, but then another person told him he needed two negative tests at least 24 hours apart.

However, Dr Githinji Gitahi, an infectious disease specialist, has assured Kenyans not to be worried over the issue of retesting for Covid-19 asymptomatic patients, arguing that people are hardly infectious after the 14-day period since infection.

“Studies worldwide have shown that a positive test result does not mean the person is still infectious.

They may be positive for the virus, but remain non-infectious. The chances of a person infecting other people after a 14 day period are close to zero,” Dr Gitahi said.

Concurring with Mwangangi, Gitahi says WHO in its latest guidelines has ruled out the necessity for re-testing after studies showed that the virus has a lifespan of 14 days in the body.

According to Gitahi, no negative test for the virus is needed before a hospitalised person can be discharged.

He says the previous requirement of retesting admitted patients to confirm their status had been done away with due to the strains it had placed on public health facilities and medical personnel and the patients.

“Apart from the strain on the facilities, it was also stretching the patients’ mental capacity. I remember when we began this quarantine exercise; some people were being forced to remain in the facility for as long as 40 days waiting to be re-tested.

And even if they were tested for the second time, they had to wait for the results to come out negative. This was a waste of time and resources.” 

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