Flying blind? Disorder, shortages undermine large-scale COVID-19 testing in Ukraine

Large-scale testing is key to controlling the spread of COVID-19. But that may be difficult for Ukraine to achieve.

The World Health Organization distinguishes between “mass testing” – screening every person — and “large-scale testing” – screening everyone with respiratory symptoms and their contacts. The WHO and former Ukrainian health officials agree that large-scale testing is the right strategy for Ukraine right now.

“The World Health Organization considers that the surveillance system should evolve and more testing should be performed in order to understand the outbreak,” WHO spokeswoman Tetiana Dolhova told the Kyiv Post.

On paper, Ukraine is trying to follow this strategy. The current protocol calls for testing everyone with symptoms of pneumonia and the contacts of people with COVID-19. 

Ukraine’s testing infrastructure, however, is struggling. Shortages of staff, expertise and equipment plague the health care system. The quality and consistency of testing varies widely among the regions. People are sometimes denied testing. Regional health centers and labs are sometimes stretched to the breaking point.

“Our system, it does not exist,” said Timofiy Badikov, the head of two health nonprofits and the deputy chairman at the Public Council at Ukraine’s Ministry of Health, referring to regional health centers. 

Furthermore, many people with mild or no symptoms can slip through the cracks, while contact tracking is inconsistent. Former health officials have called for more testing and better tracking to prevent this problem.  But several doctors said that Ukraine is doing the best it can under the circumstances.

“We simply lack the resources,” said Olha Golubovskaya, an infectious diseases doctor. “Today we are doing everything we can within the framework of our resources.”

Some help may be on the way. The country is awaiting a shipment of tools that will allow it to use tuberculosis diagnostic machines to test for COVID-19.

Testing goals

As of April 23, Ukraine has conducted 67,520 tests, according to the Center for Public Health. But the center does not track the number of people who have been tested, only the number of polymerase chain reaction (PCR) analyses conducted. The number of tests per day is between 3,500 and 4,500, the center said.  

Many people, especially those who have the disease, are tested multiple times. Someone is considered recovered only after two consecutive negative PCR results. Doctors who spoke to the Kyiv Post estimate the actual number of people tested is much lower than the number of tests.

Pavlo Kovtonyuk, a former deputy health minister under ex-Minister of Health Ulana Suprun, said that while Ukraine is “crawling in the right direction,” it has a long way to go until it starts doing the appropriate amount of tests. Given the number of potential contacts each infected patient has, the country should be doing thousands more tests per day. 

“There is a direct correlation between the number of tests… and the level of infection detection,” Viktor Tretiakov, a doctor of infectious diseases, wrote in an email.

PCR testing got off to a slow start in the regions, largely due to a lack of equipment. Once all the regional lab centers were plugged into the testing process, Ukraine started ramping up.

Ihor Kuzin, the acting director at the Center for Public Health, and chief sanitary doctor Viktor Lyashko said the ramp-up was limited at first because the total number of suspected cases wasn’t growing fast enough to justify using the labs’ full capacity. 

Kuzin said testing the entire population, including healthy people, would put a massive strain on the system while not producing actionable data. It’s unlikely that Ukraine will change its current strategy of targeted testing and contact tracking, he said. 

Doctors were split about this protocol. For example, Tretiakov told the Kyiv Post that the national testing strategy “is perfectly acceptable and can be considered effective.” But Yevhenii Cherenok, director at Boryspil’s Primary Health Care Center, wrote that this approach misses asymptomatic carriers.

Studies have shown that about half of all coronavirus transmission is pre-symptomatic and GlobalData estimates that two thirds of COVID-19 cases may proceed undiagnosed.

Kuzin said that the 43 laboratories that are currently performing PCR tests are working at over 75% capacity. However, doctors who spoke to the Kyiv Post believe that percentage is higher. Two weeks ago, Kuzin said that the labs were working at just 30%. 

The WHO’s Dolhova said Ukraine needs a “plan B” in case laboratories are overwhelmed with samples. This will require all available resources from laboratories throughout the country, including HIV and tuberculosis labs.

Equipment shortages

The Center for Public Health and its regional counterparts are the organizational backbone of Ukraine’s COVID-19 testing strategy. 

Many regional centers are in the very early stages of being created, Badikov pointed out. Some just gained approval by local authorities last year. Some exist only on paper. A few more developed centers exist in Kyiv, Kherson and Rivne.

“The service is very understaffed,” said Badikov. “This was (due to) sabotage and resistance from local authorities.” They are also underfunded, he claims, with many employees receiving minimal pay, despite taking on a greater and greater workload amid the unfolding pandemic. 

Lab centers are not doing any better. They, too, are understaffed, with an aging workforce. Meanwhile, Badikov said, the pay is so low that they’re unable to attract younger talent that would boost the labs’ capabilities.

The Center for Public Health’s Kuzin said that, while Ukraine’s labs are adequately staffed, they have had to work around the clock without relief. Badikov said that these stressful conditions and lack of sleep whittle down lab workers’ immune systems, putting them at risk at a time when Ukraine needs them most.

“Everything hangs on these people,” said Badikov. “They are barely holding on. If this continues, they will simply get sick.”

Kuzin said that the government has decided to include private laboratories and medical schools and has reached agreements with several of them. A protocol for their inclusion in the testing process has already been created.

Doctors previously told the Kyiv Post that cooperation with the private sector had been limited due to a culture of distrust and the lack of a mechanism to give private labs materials bought via public funds.

Golubovskaya added that Ukraine has practically destroyed its sanitary-epidemiological service over the past five years. No new epidemiologists are graduating from medical schools at a time when they’re most needed.

Larger-scale testing would also require many more medical workers taking samples from people. There will be a shortage of these workers as well. Worse yet, many are falling sick due to protective equipment shortages and a lack of proper hygiene. Almost a fifth of Ukrainians with COVID-19 are medical workers. There is also a shortage of sampling materials such as swabs and test tubes. 

Poor conditions and errors

The health ministry has identified errors in following the national testing algorithm, such as in Myolayiv, which had been reporting zero cases and few suspected patients until an inspection by the health ministry two weeks ago. Since then, the region started reporting a growing number of COVID-19 cases.

Errors in test results are possible, too. Vladislav Denysenko, a tuberculosis specialist, said he has seen reports of samples taken or transported incorrectly, thus leading to possible misdiagnoses. For example, a virologist told the LIGA.net news website that the use of wooden swabs instead of plastic ones, as well as poorly sealed packages, have led to errors. 

Outdated equipment and insufficient lab space also play a role. Denysenko said that the gold standard for PCR labs is four separate rooms for each stage of the process with precise control over air pressure and quality.

These conditions are hard to achieve in most government labs. Many have just two rooms, which makes it hard to avoid cross-contamination that can taint the results.

Read more: How Ukraine compares to other countries in coronavirus tests

Inconsistencies

Former Deputy Health Minister Kovtonyuk said that he has gotten reports of inconsistencies among how well regional centers track patients’ contacts and how diligently medical workers collect testing material.

Denysenko agreed. Due to the disorganization of the health care system, it’s hard for family doctors to launch the procedure to collect material from a patient, send it to the lab and take down all their contacts for tracking and later testing.

That’s why many doctors prefer to write off light respiratory symptoms as unrelated to the coronavirus and send the person home, recommending that they stay in isolation for 14 days. This leads to many potential carriers walking around, which defies any attempt to conduct meaningful large-scale testing. 

“A person gets symptoms, goes to a family doctor, the doctor calls an ambulance, it doesn’t come or it sends him back to the family doctor,” said Denysenko. “In the end, the person does not get tested.”

Ulana Suprun, former acting health minister, posted on Facebook that people have written to her complaining that they were denied testing. 

A lack of epidemiological expertise at the regional level also leads to inconsistent contact tracking, health experts told the Kyiv Post.

No strategy for rapid tests

Rapid tests, such as those that test for antibodies in blood, still don’t have a clear role in the national strategy. 

The WHO said that there is insufficient data to support the diagnostic value of rapid tests and does not recommend them for diagnostic purposes. 

However, rapid tests have value as epidemiological tools to track the progression of the virus, transmission dynamics, as well as the status of recovered people.

Read more: Types of COVID-19 tests, which ones work better?

Useful tuberculosis tests

Ukraine has 150 GeneXpert machines produced by U.S. pharmaceutical Cepheid, which have been used to diagnose tuberculosis. These can be used for fast, accurate COVID-19 diagnosis. They require significantly less manpower than standard PCR tests and each sample can be analyzed in less than an hour. 

Kuzin said Ukraine is ready to start using them, but first requires the delivery of cartridges from Cepheid. Ukraine expects the first delivery of 50,000 cartridges to arrive at the end of April. This would allow Ukrainian labs to do another 4,000 tests per day. 

While health experts are optimistic about the use of GeneXpert, the global shortage of diagnostic tools may get in the way of Ukraine receiving these tools quickly, said tuberculosis specialist Denysenko.

Furthermore, the health ministry’s latest troubles with procuring drugs — the process stalled due to bureaucratic issues tinged with possible corruption — make him concerned that some officials may get in the way of the pending delivery.

“There’s suspicion the ministry may not reach an agreement to send a transport to pick up the supplies,” Denysenko said.