Professor Koleka Mlisana, Executive Manager of Academic Affairs Research & Quality Assurance National Health Laboratory Service
“NHLS preparing for the second surge”
Moderator: Tian Johnson
Complied by: Anna Matendawafa – with inputs from Wilfred Gurupira & Maaza Seyoum
Webinar Recordings & Supplementary Materials:
Date: 20 August 2020
Professor Koleka Mlisana is the Executive Manager of Academic Affairs Research and Quality Assurance at the National Health laboratory service. She’s been in that role since July 2018. Before this, she was the head of the department at the Medical microbiology at UKZN lALCH and served as an NHLS board member. She has been previously active as an HIV and AIDS researcher for over a decade, focusing on HIV prevention and pathogenesis working at the Center for the AIDS program of research in South Africa(CAPRISA). She has undertaken seminal research, which has revealed how the body responds during acute HIV infection. The current research interests include TB diagnostics, antimicrobial resistance, sexually transmitted diseases, and has co-authored more than 130 peer-review journal articles. She continues to supervise postgraduate students as well as examining postgraduate thesis from various academic institutions. Professor Koleka currently chairs the pathology laboratory committee on the recently established ministerial Advisory Committee for COVID-19. She serves as a member of the Ministerial Advisory Committee on antimicrobial resistance and is a member of the Board of Trustees for the South African National AIDS Council. She has nurtured and mentored many young scientists. The passion is to groom the next generation of leaders and scientists to be well-rounded individuals academically, socially, and spiritually.
QUESTIONS AND ANSWERS
*This section contains a transcribed account of the Question and Answer Session
Could you speak a bit more to your intention of engaging civil society in the revision of the revised strategy? And if civil society has been engaged, how has that happened? How did we get to a point where tests became so expensive?Can you speak to a bit more about the impact that clinical trials are having on the testing resources? Is there any relationship between the research and the National Health Laboratory Service(NHLS) services?
Alright, thanks for those, and I think those are important questions. So, I must say, actually, now that you’re raising this question of civil society engagement when it comes to testing, and from the Ministerial Advisory Committee (MAC) , we have not been doing that, I must be honest. But you know everything has been very technical. And what then usually happens is that we would then put together an advisory, and then that advisory goes to the Department of Health. And I suppose then it’s at that level, where then the implementers of the advisories would engage with everybody that probably is an area you know, we need to look at and see how we can then do plus a member. You know, how the map was formed is that the Minister identified us, and so is whoever is there, and to find that it just is purely technical individuals. So there has not been much engagement with civil society. And we would need to see then and explore if there are areas where civil society, there are ways and means of making sure that there’s engagement at that level.Why are tests expensive? And, you know, there has been a lot of discussions to and fro about this. Remember, this will be now in the private sector because, as far as the NHLS is concerned, we have proposed a cost to the government that they have agreed upon. And there have been discussions if you were the question was, shouldn’t the government be directing the pricing in the private sector. Still, if I, if my memory serves me well, I think a lot of private labs have used their testing and the R1000, you know, the costs of more than R1000 it was initially, but then when discussions were going ahead with that, you know, the private sector had to come up with a with one price. And I know that it is not more than R1000; I think its around R600 or so. So the tests have come down. And so it just really depends. And if they have not, in other, in specific private labs, one would need to find cheaper labs because, right now, there is no need for tests to be this expensive. And whatever clinical trials, ready clinical trials do not affect the testing within NHLS, because what often happens is that every, whenever there’s a clinical trial, the researchers usually identify a lab that does testing, and I don’t think we are doing such high numbers that you know, the clinical trials would harm our ability or capacity to test. So I’m not worried because right now, I mean, as you can see, we, you know, we’re doing such low numbers anyway. So there’s more than enough capacity, and that we’ll be able to take care of whatever labs, private labs, or other labs that are doing testing for the clinical trials. Over.
Do you have any additional clarity on reinfection? Are you noticing any trends there?Can we as activists and community organizations stand up and as they say, speak with our chest and say we are confident in these numbers? And at what point do we get to say we are 100% confident in these testing numbers? Can you speak a bit more about the laboratory capacity.What is the coordination of laboratories across the country, both public and private. And is that coordination happening and what are you seeing from that coordination of laboratory services and testing services across the country?
Okay, so, reinfection. I smile when you raise reinfection because we’re currently actually drafting an advisory on reinfection. So that’s why I didn’t want to talk about it, and we know that people are now starting to ask those questions. If one looks at the literature, there has not been any confirmed evidence that’s confirmed of reinfection. So what we are busy doing now is to look at the literature globally, what is happening, what has been seen in situations where you find someone who was positive, have the infection had everything else, and test negative. One or two times, I think that three or four papers were publishing those case reports, and then after being negative once or twice, they became positive again. The question is, what is happening then. Rarely when you follow those case reports, these are individuals remember we are using polymerase chain reaction testing (PCR) which is we picking up genetic material. So what happens is, and we know this phenomenon for any other PCR test, in that the genetic material does not tell you whether the virus is replicating or not. It is just a piece Ribonucleic acid (RNA); you will pick up RNA if you use a DNA virus and pick up DNA. We know that when people did a comparative test to look at the PCR versus viable virus where they grew and cultured the virus, we have not seen any viable virus beyond ten days of infection. Whatever positive PCR beyond that, we believe it is the degenerative and genetic material. Now, depending on when you do the test, or when you don’t, sometimes you might pick it, and you might miss it. Or sometimes you might; it might appear after a few days when it was negative. And we think well, that’s just what it is. So we are still yet to explore and see and follow cases to see whether infections are carrying, but for now, there has been no published case of a clear cut of reinfection.Confidence in testing numbers. I’m not sure where that person is coming from because as you know, as I have explained, rarely the number as a way of reporting on daily, those are the numbers that we are testing in the country because that every lab that does testing, they’re supposed to make sure that those their numbers get reported to NICD if they are in the private sector. And in so far as the public sector is concerned, so NHLS has got, you know, a footprint across the country, but we use one single laboratory information system. All the data goes on to our LI’s, and that data every day, it gets downloaded, as I said, onto NICD. So NICD combines both the private sector as well as the public sector data. The numbers that we’re reporting are the numbers that are getting tested in the country. The only issue would be if there are labs out there that we don’t know which should not be happening, and they are not reporting their numbers. Still, otherwise, every other lab operating within the country’s framework work should be submitting their numbers, and we get that every day. So I have a lot of confidence in the numbers that we have and the numbers that we’re reporting on, especially for testing because I present those numbers myself, okay. And then the capacity. So when I was talking about 27 and 25, it’s 25, whatever, one in the public sector and the private sector. So when we then look at the capacity to do the testing, we have just done that exercise as NHLS. We looked at the platform that we have; we looked at the available reagents that we currently have. We’re now confident that, you know, NHLS would be able to go up to as high as 28,000 samples per day. We can test that and if you are looking at the private sector capacity is another 25 to 30,000 as well. So really, when you look at this as a country, we’re basing this on the numbers that we have seen before, and capacities that labs have shown before we can comfortably do 50,000 tests. Now, this is provided, there’s a regular supply of reagents, and human resources are available to do that because we’re talking 24-hour labs so really. This is across the platform, sorry across the nation in that in every province; there are testing labs. So there’s a good footprint across both the private and public sectors. I think I’ve addressed all the questions that you raised.
What are your thoughts on mass testing?So now the economy is open. What does that mean, for testing?There was talk about a social behavioral group team being set up. Can you maybe give us an update in terms of how far that advisory group hasn’t been set up terms of reference been establishedOkay, thanks. So mass testing, you see, if we had the capacity and resources, as we had said, initially. As the outbreak started within the country, the Achilles is to make sure that we test as many people as possible. So that would be ideal, but we probably are now beyond that. Because, you know, when we try to do it, we failed because of some of the reasons that I have already highlighted, and so where we are right now, I don’t think mass testing would make a big difference unless we have got different diagnostic methods. Because remember, right now, all we have so far is still PCR and detection. There are now serological tests that have just been approved by The South African Health Products Regulatory Authority (SAHPRA) and are also looking at approving antigen detection tests. And some of these, they are rapid tests. So really, mass testing would be ideal if we have a rapid test. And the question then would be when I look at mass testing, what are we trying to do? There can be mass testing, looking at prevalence, in which case, populations with the infection. We are looking to see how much infection is there and use serological tests and antibody detection tests. And as I’ve said, some of these are rapid. So that would work very well. Or if you want to look at people infected, then the antigen test would come in, we don’t have one test that’s approved as yet, as for antigen testing, but there should be one soon. So when that test becomes available, we can then explore and say, Well, maybe we could increase the net of the people we’re testing. So right now, for as long as we’re still using PCR, there will be limitations, and mass testing will not be ideal. Open economy, yes, that’s why we are talking and our consent of a second sedge because as people flood to work. It was good to hear the President stressed that people need to continue with social distancing wearing off masks and washing hands because that is really what will contain another surge. But you know, you and I people forget. We don’t know what’s going to happen as people get back to work, whether they will keep the distance or not. Therefore, we, that’s why in my last slide, I was saying we need to gear ourselves up for a situation where with the opening of economy, you know, more relaxed, rules around, movement, then we might end up with another surge. And that’s what we’re trying to do and make sure that we’re prepared for that. The social, behavioral advisory, yes, there is Ntando, and it has been established, because in one of our advisory committee meetings, we shared it with them, and we were introduced to them. So that advisory committee is up and running, but I must say, I don’t know where they are, what’s happening in that and so that’s something that you know, we could you could explore and see who is in the in that advisor. I know, there are lots of civil society and members, and even members of the clergy, you know, and different, you know, and members that are part of that committee, but as I say, it has already been established. Could you speak to the efficacy of contact tracing as a mechanism? Then, could you give us your I’d love to say final and full stop ruling on the temperature machine.Where do you get your funding from? Has solidarity come to the party?Is solidarity, welcome to the party with their billions have already been to the party. So could you touch on the temperature machine contact tracing efficacy and solidarity and your funding?Okay, can I skip the temperature question? Anyway? All right. Yeah, I guess I don’t have a choice and contact tracing. Remember, when and because of the nature of transmission of the virus, it now droplet spread as we all know. And there’s also you know, concern about aerosol as well. So, the whole idea is that people who are close in close contact, they are the ones that are highly at risk for transmission. So, if we were to do contact tracing effectively, in a situation where I developed symptoms now. The challenge and that is why it makes conduct tracing critical, is that we know that the virus you shed the virus if you are infected as early as day one or day two of exposure, so it is very early on. Even while you are still asymptomatic because of what happens, you get the subclinical phase, and then you come up with symptoms, so you’ll find that you can get infected on the day only manifest with symptoms on day two or three. Even on day two, you would have been shedding the virus; therefore, you risk those around you. And obviously, depending on the severity of the disease is also related to the virus, I mean to the viral load during infection, so that’s why it becomes the end. The other danger is when data shows that even people who don’t manifest with symptoms are asymptomatic and can still transmit the virus. So that’s why then contact tracing becomes essential, because if I present with symptoms and assume I’m at day three or four of infection, then I need to be able to identify people that have been close to me for the past two years and two years, two days, and then everybody else around that time and if we can do that effectively. Because, because then, we’ll be able to identify, go into those contacts and test them. And we’ll find that when conduct tracing is done efficiently, you’re able to pick up many infections. And we saw this happening in the Western Cape, they, for some reason, they had an excellent system in that when they were testing, whoever they end up with a very high positivity rate because it means their testing was targeted amongst those with high risk. So it really can be a very effective way of identifying those that are infected. Temperature measuring and everybody is doing this.Yeah, I wish I could say, you know, I should not be recorded on this one. This morning when I walked through our gate, my temperature was 33 point something I said, Oh my goodness, a probably must in the mortuary dead. We know it’s such a low temperature. So I mean, they’re pros and cons to this temperature testing because remember, you know, especially some of the instruments used. If I’ve been sitting in my car and my aircon is always on, whether winter or summer. So I mean, the surface of my skin will be cold. And so it also depends on how the testing is done, and that it can’t just be monitoring the temperature alone, there’s got to be other things that you look at. And that’s why when we are talking opening the economy, it can’t just be that, you know, that printing of the temperature, but what about the other symptoms? There’s got to be like a daily screening in our list that everybody goes through, and not just the temperature, let me leave at that .Then, the resources for NHLS I must say that yes, thanks for bringing that in, the Solidarity fund. NHLS, our revenue get we get it from government, by you know, through the testing, in the test that we’re doing, And so what happened was, when COVID started, yes, were given a donation by the Solidarity Fund, which had a great deal. A lot of the initial testing was paid because we only really started billing the government. I think it was last month or something. So for the other, you know, months, it had been funding that came from Solidarity Fund. So we did access money from the Solidarity Fund. And also, when I was talking about the academic laboratories that came on board for testing. They also have funded; they are currently supported by the Solidarity Fund to do testing. So there is that funding available as well. So we have managed to get you a few millions of the billions.
Prof I think you had a pretty impressive career in TB and HIV, you are nurturing young minds ,putting in a lot of important work . Going into COVID what struck you the most in terms of taking a moment to reflect and look back and apply these decades of your leadership and your influence in the space to when COVID has arrived? What are some of the key lessons that you’ve reflected on during this few months of COVID and any similarities between your work around TB and HIV.
Yeah. One of the other vital things about us South Africans, which always amazes me, is how we can come together during a crisis. One saw this, even with COVID as well, just as we saw it in HIV during the early days. We saw this, in that, like I was saying, even at testing level, you know, didn’t matter whether you were private or public, we were all running around each other and see how best can we do this. And even when we had backlogs, the private sector covered up and did some of the work for us. And so there’s this resilience, you know, with South Africans when we’re faced with a calamity, and we’re able to come together. What one has realized is that we need to be anything is a lesson for the future. That because I’m sure COVID is not the last pandemic that we see globally; there will be another one coming in. What we’re now realizing is there the reality and the scare of how a new pandemic can negatively affect gains that have been made on other infectious diseases specifically. And I’m saying this because right now we are, what, four months into COVID. When we now look at what about the other programs that we have in the country, and we’re concerned with the fact that we’re looking at the TB program, it seems to have been negatively affected in that the TB testing numbers have gone down. And now we are trying to understand that, and it says to us going into the future, whenever there’s an epidemic that comes, we must always make sure that epidemic doesn’t take precedence. And we then forget to look after other successful programs. I mean, we have been saying this, but we didn’t think it was going to be this much. But I think we’re waking up to realizing that we need to strengthen, especially if, for some reason, it’s just in the TB program because we don’t see a big difference in Viral load testing and HIV management program, so we’re still trying to understand what could be causing that. So for me, you know, and it’s saying, when we make gains, we’ve got to try whatever it’s going to take to make sure we sustain those irrespective of what other calamities we face. And we need actually to learn and find lessons on how to do that. And we still try to analyze the typical as a scenario.
What would you say is a key low hanging strategic opportunity for us as advocates and civil society to engage with your work and support your work, especially as it relates to getting communities mobilized and aware?
Yeah, I think that that’s probably something that we still need to work at. And I think lately within a no talking pathology. Generally, we are awakening to a reality that the public doesn’t understand pathological services at all. I mean, and we maybe even before we can reach out to civil society and find common ways of working together, we need to establish ourselves and appreciate the difference we make in health generally. And I don’t think we have articulated that very well, as a result. As you say, people don’t really understand, I mean, if now if I were to ask, you know, a few members sitting here what is their full understanding of NHLS. Last night, somebody was asking, what is NHLS is on Facebook, what does it do? And how does it relate, you know, to hospital services? So I think we may be as a field, we have not marketed ourselves effectively. And that’s the first thing we need to do. Because, when you look at it, I always say, and this is me now a mother saying to my children when they ask what do you do. You understand the scope, but you said you’re a doctor. Are you a real doctor? They used to ask me this so often, but what now? I tell them that we actually are diagnostics, we’re actually the brains behind the doctors, because we actually, there’s no way you can make a diagnosis without laboratory services. And so we are very vital and we need to make that known and get people to appreciate that. We would probably need to see how we can interact and engage with civil society in highlighting that. I mean, for instance, we are talking about TB testing. I know there’s a lot of advocacy around TB testing. We should be rallying around now that I’m saying there seems to have been a decline; how then do we get civil society to assist us in making communities aware that it’s essential to continue with your TB treatment, as well as TB testing. We don’t forget that because of the pandemic. And secondly, as far as vaccines are concerned, I mean, I will tell you, I’ve worked HIV vaccines as well. And I think for me, we do need to find a vaccine for SARS-Covirus 2. People need to participate in these trials to come up as South Africans if we can make sure that we participate so that we can have an answer that talks to our country, and in a trial that has had enough participants for the country. So that the data analysis, we’ve got enough data that comes from the country because then whatever decisions and whatever outcomes that come off, we will have a lot more confidence in those and apply to where we are. So I would encourage you to know, advocacy around vaccines. The other big area, mainly because now we come to level two, is going to be how civil society can assist us and everybody else within health in preaching these non-pharmaceutical interventions. That’s the only thing that we have so far for preventing infections, so people the message of social distancing, the message of masks, the message of handwashing, and sanitization, so it still needs to go. The fact that we have moved to a level lower does not mean we are over the woods yet. And we want to make sure that we can keep the transmission in check before we get another surge that we cannot handle. So really, it would be for me to say to civil society, let’s continue to get out to communities and make them understand why it’s essential to make sure that these interventions are stuck to and adhered to. Thank you