“Stop!” a masked man raises a gloved hand in front of a Toyota, his image visible in the blacked-out windows.
Another takes over, spraying industrial-strength disinfectant over every inch of the sleek vehicle. Only then can the occupant drive through the first free coronavirus mobile testing centre in West Africa.
Within 24 hours onwards, the driver will know the outcome of the test.
On March 28, public drive-through testing kicked off in Nigeria, with 78 people tested within two days. Nigeria’s sole drive-through facility is in Lagos, the country’s economic capital (estimated population of 21 million); the coastal city is also where the first case of COVID-19 was recorded in the country.
Further afield, in Kenya, mobile testing can cost between $100 and $123, a sum out of the reach of the general public.
Nigeria’s reported 224 cases (as of April 5, 2020) and five deaths are deemed under-reported by sections of its local media and civil society groups, who urge for greater testing as the solution to combating the pandemic. The drive-through clinic was a response to this, and another concern – the safety of Lagos’ small army of healthcare workers.
“Staff were afraid; they understandably didn’t want to be infected,” says Rosemary Audu, director of the Human Virology laboratory of the Nigerian Institute of Medical Research (NIMR), who owns the car park where the drive-through is located.
“Suspected cases were coming into the institute. We were concerned because we know that a good number of healthcare workers in some other countries have come down with the infection. We had to get space outside, so that we could attend to these patients.”
The next hurdle became anonymity: several people, regardless of their income or social status, did not want to queue out in the open, for fear of stigmatisation.
A series of partnerships with private organisations resulted in the drive-through option, which Ms Audu says caused an immediate behavioural change.
Patients visit the NIMR website and fill in a form that determines their eligibility. They are asked if they have any travel history outside Nigeria, any fever, coughs or breathing difficulties, or if they have come in contact with suspected cases. Also included are those exhibiting symptoms and living in an area with moderate or high COVID-19 infections.
“We are not testing everyone that indicates interest. This is because kits are scarce, and we do not want to waste what we have now,” explains Babatunde Salako, the Director-General of the NIMR.
The website generates unique appointment codes for eligible patients, and because Lagos is currently enforcing restricted movement to curtail the spread of coronavirus, they also get a personalized pass that lets them through police/military checkpoints as they make their way to the drive-through facility.
Once there, each car gets sprayed over, before the patients can proceed to verify their data. Next, they drive up to the doctors and let down their windows, to get their noses and throats swabbed.
The Lagos drive-through uses the WHO-approved polymerase chain reaction test, which pinpoints the existence of genetic material from the virus.
The samples are immediately immersed in a transport medium that is not compromised by Lagos’ high temperatures, before being taken in batches to Ms Audu’s laboratory, which is a few meters away.
The healthcare workers change their protective clothing frequently, and the entire facility is sprayed again, after each car leaves.
Ms Audu says the extra precautions are based on reducing fear: “we know that a good number of healthcare workers in some other countries have come down with the infection. If one person comes down with the infection, it will demoralise us because people will get scared and not want to be involved.”
Each test takes roughly 20 minutes, and results are available within 24-48 hours, and delivered electronically. In cases where a review is needed, the samples are sent for further testing; positive results are sent to the Nigeria Centre for Disease Control, which then commences isolation of patients.
Majority of patients who drive-through have been Nigerians who travelled out of the country, adds Temie Giwa-Tubosun, CEO of LifeBank, the logistics partner at the facility.
The following are key takeaways for Lagos, and any other regions or countries wanting to adopt public mobile testing, based on exclusive interviews with Uwe Köster, Deputy Press officer of the Lower Saxony Association of Statutory Health Insurance Physicians.
Germany ranks among the world’s highest recorded testing rates, conducting more than half a million tests a week – this is cited as a a major reason for the country’s, compared to infections.
Nigeria’s total COVID-19 test figures pale in comparison, only just crossing the 4,000-mark. Even though Lower Saxony was an early adopter of drive-through testing, Mr Koester says the reality of the pandemic is that test kits will always be scarce, no matter the country in question.
His advice to Lagos is: “you can only do a limited number of tests. It is important that there is somebody who pre-selects the people…you have to be very careful that you don’t waste the test sets.”
In the UAE, tests are restricted to the elderly, pregnant, and those exhibiting symptoms, such that those “for the wider community for reassurance purposes only” are charged at 370 dirhams ($100).
Illustrating Mr Koester’s point is a document which leaked hours after our interview, where Germany’s scientists told the government that the country still needed to increase its testing capacity. Test scarcity has also hit the US, Spain and the UK, a situation which worries Ms Giwa-Tubosun.
“As at this moment, we have about 2000 test kits available; this is phase one…we expect to have more test kits available, when we begin the second and third phase,” she said.
- Regardless of the number of test kits available, patients must be pre-selected, to limit wastage – the unwieldy nature of the Coronavirus pandemic means test kits will remain a scarce commodity in the immediate to long-term for all countries.
While Lagos has relied on social and mass media to create awareness of its testing location, Lower Saxony does not. Mr Köster said this is to control numbers of patients and keep the centres organised. Both states have a pre-selection process that builds on existing realities – Lower Saxony makes use of family doctors to refer patients, while Lagos relies on all patients registering online to generate an access code. The shutdown in Lagos also means the drive-through website allows patients print an exclusive pass that allows them through military and police checkpoints.
In Lagos, “there were teething issues on the first day, as people flocked to the place. We later reiterated that only those given appointments and invitations should come; to date, they have been complying, said Mr Salako.
In Lower Saxony, police guards are present to maintain order, and Mr Köster says as time goes on, “it will be important in Lagos that the test station is not overrun by worried people.”
Pre-selection yardsticks and testing location operation should adapt to the populations being served, whilst prioritising safety of patients and staff.
A challenge for drive-through testing is “finding sufficient staff and suitable room,” says Mr. Köster. Lower Saxony is surmounting this hurdle by using retired doctors but “personnel are also required for the paperwork and organization of the test do that the doctors can concentrate on the medical work.”
Lagos does not seem to have a staffing problem as yet, though the workload is increasing, such that onsite accommodation is now provided because Lagos is also officially in lockdown.
“Many workers are unable to go back to their families on a daily basis as samples have to be tested overnight, in order to cope with the load. In spite of the drive-in, we are still receiving samples from the Lagos state government,” explained Mr. Salako.
One of such workers is scientist Olufemi Amoo, who said despite the challenges, he is glad to be at the frontline combatting COVID-19 in Nigeria because “many depend on one’s little efforts for their survival.”
Lagos should consider expanding its pool of sample collectors, particularly if it hopes to expand to other sites, or is forced to, by the pandemic, as is currently seen in other countries.
Lower Saxony initially used garages owned by the German Red Cross but these spaces did not allow for free movement – the shift was made to a trade fair hall, which allows ten cars to be spaced and attended to simultaneously. Testing times have now reduced to approximately 10 minutes, including a short interview, patient registration and testing.
Spacious facilities are becoming the norm in mobile COVID-19 testing, with stadiums and car parks converted for use in Ireland and various US cities.
Though Lagos’ sole centre is fairly spacious, its testing time is more than double Lower Saxony’s. However, the bulk is used to disinfect all cars before entry, and to disinfect the testing area, after each car leaves, something which Mr. Köster considers good practise.
He adds that the state limited its drive-through test centres to only two because “doctors have a duty to examine a patient more closely if they appear to be ill – there is no way to do this in a drive-through.”
Testing times may be impacted by various factors – it is not a determinant of quality of testing, so operators should remain flexible, and aware that mobile locations are restrictive; extensive medical care for patients cannot be safely provided onsite.
As drive-through testing progresses worldwide aspects of the COVID-19 logistics supply chain are affecting testing and treatment capacity.
On April 1, the UK’s oldest medical trade union of doctors issued a statement over a lack of personal protective equipment (PPE), saying it was unacceptable that some health workers “source their own equipment from DIY stores, and some have made agreements with local secondary schools to make visors on 3D printers.”
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In the U.S., a prominent Seattle laboratory reports an impending shortage of the cotton swabs used to collect samples from patients; Taiwan banned face mask exports, ramped up local production and currently rations them.
Germany has its own challenges – asides staffing, as earlier-mentioned, the reagents used in testing are drying up, produced by only three manufacturers. A similar challenge may be on the horizon for the Lagos drive-through.
“The transport medium used to preserve the viability of the samples before it gets to the laboratory is not enough now, which means it will affect the number of tests that can be done,” said Mr Salako.
He revealed that scientists at the NIMR have decided to be proactive: “we have the capacity to produce this, and we are currently helping to do that in-country.”
Mr Köster notes that testing in Lower Saxony has reached a critical point, because doctors can do a large number of tests, but “the labs are running out of capacity. It is not enough to set up test centres; there must also be enough laboratory capacity to evaluate the tests.”
To surmount this limitation, the state now uses veterinary laboratories for coronavirus test evaluations and Mr Köster proffers this as a solution Lagos can prepare towards, as test numbers begin to climb.
“In the industries of Nigeria, there are much more clinical capacities and you can switch them (laboratories in other industries) to other ways of testing. It is very important to try and switch them to this task for a couple of weeks.”
Several points of the COVID-19 treatment and response value chain may witness shortages at varying times of a country’s response – anticipating the challenges and preparing solutions ahead is key.
Amid plans by LifeBank to scale up drive-through testing to other locations within and beyond Lagos State, Ms Audu’s laboratory remains a first port of call: “many people are calling in to find out how they can get sampled and tested. If there are other facilities that want to go for it, I would recommend it. It is a wonderful method of sample collection and testing.”
Lagos is currently saddled with a little over 50 per cent of all Nigeria’s 224 reported COVID-19 cases, and its densely populated neighbourhoods, cramped transport systems are a staunch opponent to effective social distancing. Furthermore, even as the state prioritises self-isolation and testing, patient stigmatisation remains a daunting hurdle.
No journalist is allowed near the testing area, and only zoom lens can be used for non-intrusive photography.
“Some people are still concerned about anonymity and are still engaging us for a better alternative for them. We are currently looking at a scheme where we can test them at home, but this has logistic implications,” said Mr Salako.
Mr. Köster is however optimistic for Lagos: “you have a really a good chance to stop this disease. You can’t stop it completely, but you can lower down the infection rate. You have to encourage the people to wash their hands again and, as much as it is possible in a city like Lagos, to get apart from each other.”