Do We Need To Start Sending In The CATs (Common-Sense Attitude To Testing) After The RAT’s?

From the perspective of a professional body that oversees most of the practising medical laboratory workforce, RAT’s have provided a vital stop gap to gain control back in our frontline diagnostic laboratory service. But the question needs to be asked, at what cost and for how long?

As has been highlighted the transfer of responsibility for supervised RAT testing and distribution now falls firmly upon the primary providers within the Health sector. It is the classic hot potato of health service responsibility that has dogged all COVID pandemic responses from every corner of the world. But for Aotearoa New Zealand our problems were compounded by the success of our initial elimination then suppression strategies over 2020 and 2021.

The public rightly were told to get tested at every opportunity throughout the pandemic. We had a laboratory service that for the most part was able to handle most of the testing challenges thrown at it. This was an absolute credit to those dedicated staff who devised systems and strategies to cope under pressure during testing surges. But looking back the warning signs were starting to show as most of the country eased into their summer holidays.

Some of us were understandably nervous and worried. Two years of constant pressure and toil was taking its toll on a service that wasn’t in stellar condition for a start when the pandemic hit in March 2020. Laboratory services had up until now, always been the poor cousins of the Health and Disability System with frequent restructuring and contracting out by DHB’s and no representation in Health leadership. Medical laboratory scientists are specialized medical practitioners that take years to train, and there was no ready-made pool waiting to walk into our laboratories. Many people stepped up and took on the pre-analytical and less technical roles but ultimately, we were relying heavily on a few of our most talented and experienced molecular scientists. The strain was starting to show and the full laboratory hierarchy were all aware that we had much more to come.

And the stark realisation hit us close to home over the early summer when NSW and then Victoria were overrun by the new COVID variant on the block, Omicron. I remember vividly on Christmas Day going through every shred of data and all the media reports and sending several email requests off to our Australian colleagues for some advice on how best to deal with what was coming for our beleaguered workforce. I was very aware that there would be a blame game coming when things got hot and unfortunately in Australia it was the laboratories that bore the brunt of this anger. This was worrying as the leader of the NZIMLS, particularly knowing how fragile a position the workforce really was in.

The plan needed to change from the ingrained test, test, and test mentality and as reluctant as all scientists and microbiologists were, we had to have options to preserve the PCR testing for those that clinically really needed it. This was going to mean transferring to the community an inferior testing regime relying on Rapid Antigen Tests (RAT) when the lab capacity was nearing the plateaux. There was disappointment that more work had not been done on getting Loop Mediated isothermal Amplification (LAMP) tests widely available to roll out as we knew that they have an accuracy very close to the gold standard PCR tests. It was plainly obvious knowing what our diagnostic laboratories could handle with regards to PCR testing and how our testing strategy would have to change from pooling samples to individual testing as the positivity rate started to increase.

One of the key warnings from Australia was the effect of completely swamping the COVID PCR testing at the expense of all other diagnostic services provided by laboratories. The question is always at what cost is it to have so much resource put into a part of the laboratory that causes major changes in clinical outcomes for patients who are relying on our core and speciality services. These are pertinent questions to ask when dealing with a crisis like this unfolding. As someone who deals with testing some of the sickest patients in the health system to see perfectly well people complaining about how long it took for their PCR tests was like crocodile tears with this real worry in the background.

As a medical laboratory scientist with 30 years diagnostic experience, I would never be using a RAT test for diagnosing anything without a significant 2nd line of confirmatory tests. In fact, there would have to be the strongest clinical indication to ever use this technology over more trusted and accurate technology. In saying that RAT’s are here and they are fulfilling a vital role for scientists like myself in taking the pressure off our diagnostic laboratories.

The new normal is different from 2019 when if you got a cold or flu-like bug there would never be a diagnostic test to follow. But the COVID-19 virus has caused a pandemic and killed millions and millions of people and left many more with lingering health issues. RAT’s have found their niche as a quick and easy test to give an answer one way or the other. Is it the right answer? I would debate that many hundreds of people throughout the motu have been given the wrong answer but at least there is an answer. The piece of mind from this might just be enough to get some people through this difficult time.

So what have we learnt so far? Omicron is rampant and has no care for testing or health care issues. The virus just wants to survive and impart its RNA into as many human cells as it can and quickly so it can spread to other human hosts without being thwarted. We have successfully mitigated the health issues by vaccination and the public health measures, and someone likes me hopes that the virus continues to mutate and lower its efficacy and turn into just another coronavirus like the common cold. But then again COVID-19 might have other ideas. The certainty for the future is that the Common-sense Attitude to Testing (CAT) is something that will need to be talked about sooner rather than later.

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