Why Canada’s COVID-19 ‘war-time’ response could be derailed by a swab on a stick
A distorted picture of Canada’s COVID-19 epidemic is emerging as a result of gaps in the ability to test for the infections.
With testing being rationed across the country, it’s impossible to know how to read the signs.
For example, a sudden spike in case numbers could be a sign of a disease flare-up. Or it could also be a sudden surge in test results.
A low total number of confirmed cases could mean Canada is getting the disease under control. Or it could be a sign that we’re just not testing enough people.
Politicians and public health leaders keep promising to increase testing capacity, but they’re up against some difficult realities.
There are not enough supplies, not enough machines and potentially not enough trained staff ﹘ all choke points that are causing critical delays in testing patients and controlling the disease.
“Everything is a choke point. If it wasn’t yesterday, it will be today or tomorrow.” said Dr. Allison McGeer, an infectious disease researcher at the Lunenfeld-Tanenbaum Research Institute in Toronto.
‘Priority of priorities’
Health care workers are at the front of the line for COVID-19 tests in many parts of the country. But being a priority for testing doesn’t guarantee a quick result.
One Ontario doctor, who didn’t want her name used, said she has been waiting eight days for test results. Two colleagues tested at the same time are also waiting for results, she said.
All three doctors have recovered from their symptoms but can’t go back to work until they get the testing all-clear.
“We need faster testing to shorten the gap between presentation and contact tracing so we can get on top of this thing to curb transmission and get health care workers back to their jobs,” she said.
On Tuesday, Prime Minister Justin Trudeau echoed this sentiment, saying, “We’re hearing that some doctors and nurses are waiting more than a week to get test results. Obviously, that skews the numbers of how big a problem this is.”
In a phone call with the prime minister, Quebec Premier François Legault said help with testing was at the top of the list of requests.
“I repeated to Mr. Trudeau that the priority of priorities is medical equipment to be able to do the screening tests,” said Legault at a media briefing Tuesday.
“We have to be certain that we have sufficient equipment in the next few weeks and months to be able to continue doing more screening tests.”
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The swab shortage
One of the weakest links in the testing chain is the simple nasopharyngeal swab.
The swabs are inserted into a patient’s nose and then sealed into a tube with a transport growth medium that keeps the virus alive until it can get to the lab.
Around the world, countries are desperately looking for the swabs. Even Iceland is running low.
As a result of the shortage, Public Health Ontario has approved the use of swabs normally used to test for other pathogens, including chlamydia.
How did the global pandemic response to COVID-19 risk being derailed by a swab on a stick?
Most hospitals keep a short-term supply, a form of “just-in-time delivery” common to the broader marketplace, where supplies are delivered as they are needed.
It works in normal, non-pandemic situations, but now, Canada is competing with the rest of the world to buy everything from swabs to masks to testing kits — including the U.S., where many of these products are made.
Another weak link in the testing chain are the chemicals needed to put the patient’s sample through a PCR machine to isolate bits of the virus and determine if the patient is infected.
“The supply chain for the clinical labs for actual tests is getting to be very constrained, to the point where we’re probably literally days away from running out of key components,” said Jim Woodgett, director of research at the Lunenfeld-Tanenbaum Research Institute.
RIght now, most provincial labs are running at full capacity, with each PCR machine able to do about 96 tests every three to four hours. That’s not fast enough.
In Ontario, the backlog of tests is growing every day. The CBC’s Mike Crawley reported on Tuesday that Ontario testing centres are sending about 3,000 tests per day to the labs. Yet those labs are only able to produce about 2,000 test results per day.
Right now, Ontario has more than 10,000 people waiting for results.
“We all would want more tests,” said Dr. Theresa Tam, Canada’s chief medical officer, at a media briefing on Tuesday. “One has to recognize there’s some flexibility that has to be provided depending on the circumstances, but we all want to up our capacity.”
One thing Tam and other leaders could do is start to ease the red tape so creative solutions can be put into action, said Woodgett, who is working with scientists at four of Toronto’s hospital research labs to develop a way to increase testing capacity.
The team is racing to develop a clinical trial protocol for alternative testing systems using research-grade materials that will meet an acceptable clinical standard.
“They’re not components that are part of the usual clinical testing supply chain, because we know that’s being exhausted,” said Woodgett. “So what we’re doing is testing and collaborating with the clinical labs to ensure they meet the right quality control.”
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It might also be possible to allow university labs to conduct tests on the patient samples, even though they’re not accredited to do that now. It could increase capacity and take some of the burden off the provincial labs.
Woodgett compared it to the way a field hospital can safely treat patients in an emergency.
“In the same way a military hospital in a battlefield doesn’t have the same standards as a conventional hospital, we have to relax standards to some degree to allow us to respond as if we’re almost in a war-time mode, but as safely as possible.”
The risks of broader testing
Already, lists are being drawn up of potential researchers who know how to use the equipment but would need to be trained for work in a clinical setting.
The idea isn’t favoured by Christine Nielsen, chief executive officer of the Canadian Society for Medical Laboratory Science (CSMLS), which represents professionals who work in provincial testing labs.
Nielsen said her members don’t want to work beside people who aren’t officially qualified.
CSMLS members “offer a level of professionalism and support that has been trained in them for three years. You can’t just bring somebody in and show them what to do in two days,” she said.
“The risk is false positives, false negatives, inappropriate infection control processes. A huge range of risk.”
Woodgett is calling on political and health leaders to provide encouragement and start figuring out ways to manage such hurdles.
“There are a lot of people who feel very uncomfortable because this is not their normal way of operating. But I would say this is not a normal circumstance we find ourselves in,” said Woodgett.
“I want [those leaders] to be thinking about where we’re going to be in a week’s time. If they need time to dismantle some of those roadblocks, now is the time to start.”
Tara Moriarty, an associate professor in the University of Toronto’s faculty of medicine, started a petition calling on federal, provincial and territorial leaders to temporarily relax regulations to increase testing capacity.
She said it’s part of the strategy other countries have used to contain the epidemic.
“As researchers, we observed that in countries such as Germany and Korea there were early, widespread efforts to develop innovative technological responses to COVID-19 that were crucial for supporting and sustaining the capacity of diagnostics labs to identify and trace the contacts of people infected with COVID-19.”