Testing & Surveillance: Democratic Republic of the Congo

The Democratic Republic of the Congo (DRC), along with three other countries, was selected for this study a priori (not through an Exemplar country selection process). These countries were selected for their variability in COVID-19 response and outcomes, their experience in managing past epidemics of global concern, their strong partnerships between in-country research institutions and ministries of health, facilitating access to data and enabling the translation of findings to action, and the representation of Francophone and Anglophone communities to enhance South-to-South collaboration. While the DRC is not a positive outlier with respect to its COVID-19 response, there are transferable lessons for other fragile states that can be learned from how the country addressed challenges. Furthermore, documenting the country’s response may also inform improvements for future preparedness and response efforts.

This research and analysis were conducted by research partners at the University of Kinshasa and the Makerere University School of Public Health.

Introduction & Key Takeaways

Between March 2020 and June 30, 2021, just over 200,000 COVID-19 tests were conducted in the DRC, with more than 41,000 people testing positive.¹ The country also recorded 933 confirmed COVID-19 deaths. The DRC’s experience with epidemic-prone diseases, especially Ebola virus disease (EVD), enabled public officials to leverage the coordination team, the preexisting screening infrastructure, and the management strategy of specific treatment centers as they developed the country’s COVID-19 response. However, testing and surveillance challenges persist, including limited access to testing sites and equipment, long turnaround times for test results, and limited funding, resources, and capacity for surveillance. Since the start of the pandemic, the DRC has increased its testing capacity, introduced rapid diagnostic tests (RDTs), developed a genomic sequencing strategy, and conducted two serological surveys.

As the Delta variant spread in the summer of 2021, officials in the DRC introduced new measures to control the pandemic.³ On June 15, President Félix Tshisekedi announced that schools and universities would remain open, but nightclubs would be closed for 15 days. He also reimposed a curfew, which was enforced by mixed army-police patrols, and prohibited any public gathering of more than 20 people.⁴ At the end of June 2020, fewer than one percent of people in the DRC had been vaccinated.⁵

The following findings are organized according to the Testing and Surveillance framework.

What was the DRC’s Pre-Pandemic Context? How did it Respond to COVID-19?

Disease Outbreak Experience

The DRC had extensive experience with outbreaks of epidemic disease, including but not limited to viral hemorrhagic fevers like yellow fever and EVD. Since EVD was first identified in 1976, the DRC has experienced 12 outbreaks of the disease, with COVID-19 emerging during the most recent EVD outbreaks in 2020 and 2021.⁶

Its experience with EVD enabled health officials in the DRC to use preexisting epidemic-screening procedures and systems (such as novel diagnostic tools, automated polymerase chain reaction, or PCR machines, and standard operating procedures for contact tracing) and begin preparing its COVID-19 response even before the virus was detected in the country.⁷ However, the persistence of communicable diseases (e.g., EVD, HIV, tuberculosis, and malaria measles, diarrhea, and cholera), along with the burden of noncommunicable diseases (e.g., high blood pressure, diabetes, renal failure, and cardiovascular disease) strained the health care system and surpassed the already limited amount of government resources that could be mobilized for its COVID-19 response.

Assessment of Pre-Pandemic Preparedness

The DRC used the Integrated Disease Surveillance and Response strategy to monitor and report high-priority diseases—which now includes infectious diseases like COVID-19. This integrated strategy facilitated the best and most efficient use of scarce resources. The General Directorate of Disease Control within the DRC’s Ministry of Health managed the Integrated Disease Surveillance and Response strategy, which encompassed immediate, weekly, and monthly reporting systems.

In 2018, a joint external evaluation (JEE) of the DRC’s capacity to comply with the International Health Regulations (2005) identified many areas for improvement.⁸ The evaluation noted strengths in immunization and event-based surveillance systems, reporting, and human resources; however, key areas for improvement included:⁹

1. Implementing better legislation to support the International Health Regulations
2. Strengthening multisectoral communication
3. Establishing standard operating procedures to harmonize emergency responses
4. Building the DRC’s International Health Regulations capacities
5. Mobilizing sufficient financial resources

Prior to the COVID-19 pandemic, trained community health workers performed active searches for cases of diseases under surveillance in their communities. Community health workers reported their findings to the chief nurse of their health area using paper forms. Electronic forms were being introduced slowly; case investigation forms were available on tablets, but the DRC’s mobile phone network had limited coverage.⁷ Every week, the chief nurse consolidated the community health workers’ reports with reports from health facilities in their purview, and sent a single area report to the health zone management team. The health zone management team, in turn, consolidated the reports it received and sent them to the Provincial Health Office. This office then sent its consolidated reports to the Directorate of Epidemiological Surveillance, which sent them to the Ministry of Health.¹⁰ These data guided officials’ decision-making, including the lifting, imposition, or reinforcement of nonpharmaceutical interventions and other preventive measures, i.e., data on recent surges in the number of COVID-19 cases prompted President Tshisekedi to reimpose a nighttime curfew.¹¹

What was the DRC’s Response Strategy?

In mid-January 2020, the DRC’s Ministry of Health started preparing for a COVID-19 outbreak by establishing a coronavirus preparedness committee, which met twice weekly. With support from partners like the World Health Organization (WHO) and UNICEF, the Directorate of Epidemiological Surveillance planned simulation exercises at the Kinshasa International Airport and other points of entry to test their readiness to handle suspected cases of COVID-19. The intent was to test the screening measures that had been built on those implemented at the airport during the 2018 EVD outbreak, including travelers’ health declarations, visual observation for symptoms, temperature checks, travelers’ health promotion measures, and procedures for referral of suspect cases. However, these simulations were never implemented due to resource constraints.⁷ Instead, with support from WHO, the Directorate of Epidemiological Surveillance conducted virtual training of 255 health care providers at points of entry, such as Maluku in Kinshasa, on screening travelers for COVID-19. These personnel have since screened 8.6 million, mostly international, travelers. Of these, 353 alerts were notified and investigated, and 28 cases were confirmed to have COVID-19.¹² (Symptom screens and temperature checks have limited impact and can be inefficient in the context of asymptomatic transmission.¹³ )

The DRC’s experience with previous epidemics enabled officials to leverage the knowledge of experienced public health officials. For example, staff who had been involved in the 2018 EVD response in the eastern DRC traveled to Kinshasa so they could mentor medical officers organizing the COVID-19 response in that health zone.

Because of limited funding and testing capacity, the DRC used a risk-based testing strategy that targeted symptomatic people, high-risk contacts, travelers, and health care workers who had been exposed to COVID-19. Officials also implemented surge testing in one region of Kinshasa, the epicenter of the country’s outbreak. People were invited to Martyrs football stadium where they were offered testing for COVID-19.¹⁴ Out of the total 8,372 individuals who participated in the campaign, 25 percent tested positive. Roughly 80 percent of the people who tested positive were asymptomatic.

What was the DRC’s Testing Strategy? How did it Establish Testing Capacity?

Access to laboratory diagnosis for COVID-19 is important for identifying and managing cases early, as well as breaking the transmission chain and suppressing the spread of the virus. As of June 30, 2021, the DRC had performed just over 200,000 COVID-19 tests, with 5.03 tests per confirmed case, which is below the WHO’s benchmark for adequate testing (10–30 tests per confirmed case).¹⁵ These low testing outputs per case were due to:

• Inadequate testing capacity, including equipment and trained staff
• Limited patient access to testing due to poor roads and absence of PCR testing labs in each province
• Inadequate testing supplies due to challenges in sourcing supplies from global manufacturers
• A testing strategy that targeted high-risk individuals only

Due to limited resources and testing capacity at the start of the COVID-19 pandemic in the DRC, the country’s testing strategy targeted high-risk individuals only—people with COVID-19 symptoms and high-risk contacts of confirmed cases. Confirmed cases underwent a series of tests on day one and day 10 after a positive result, as well as day 15 and day 20, if the day 10 test was still positive. If the test was positive, mild cases were treated at home and moderate and severe cases were treated in COVID-19 treatment centers , where tests were required to be negative for discharge.

In May and June 2020, with support from the Israeli government, the DRC conducted what it called “mass testing” (i.e., test everyone, regardless of their risk status or symptoms) in Kinshasa’s Martyrs Stadium. This type of testing, also known as expanded target or surge testing, makes it easier to find people who may be unaware that they are infected. The objective of the exercise was to increase access to free testing for those at risk at the epicenter of the DRC’s COVID-19 outbreak. Nearly 75 percent of the 8,372 people who participated in the campaign at the stadium were male due to women’s reluctance to be tested (this may have been linked to rumors about screening for the disease). Of the total tested, 25 percent tested positive for COVID-19 (77.4 percent male, 24.6 percent female) and 80 percent of these positive cases were asymptomatic.

Once travel restrictions were lifted at the beginning of June 2020, DRC health officials modified testing criteria to include systematic testing of travelers in addition to the high-risk groups. Since then, travelers arriving in the DRC have been required to take, and pay for, a COVID-19 test—at US$30 per test for interprovincial travelers and US$45 per test for international travelers.¹⁶

Testing Value Chain

SOURCING TESTING SUPPLIES

Researchers have estimated that up to 80 percent of the testing reagents and supplies in use in the DRC were donated by partners, including the WHO, the U.S. Centers for Disease Control and Prevention, the U.S. Agency for International Development, UNICEF, Médecins Sans Frontières, and the Global Fund to Fight AIDS, Tuberculosis and Malaria. The remaining 20 percent were procured with funds from the World Bank. Since August 2020, the Institut National de la Recherche Biomédicale (INRB) used the money generated from travelers’ payments for their COVID-19 tests to replenish COVID-19 testing reagents and supplies. Testing supplies were inventoried and ordered at the health zone level. Key challenges in sourcing supplies included an overreliance on donors to import testing supplies, as reagents and RDTs were not manufactured locally.

TEST DELIVERY

The U.S. Centers for Disease Control and Prevention and WHO provided support for both test kits and their delivery to provincial areas. However, international travel restrictions led to stockouts of test kits and the delayed delivery of testing supplies, as well as the distribution of incomplete supplies like extraction kits, swabs, viral transport media, and personal protective equipment.

SAMPLE COLLECTION & TEST DEMAND

At the start of the pandemic, only the INRB performed COVID-19 testing in the DRC. Its maximum capacity was 200 tests per day. The limited testing capacity contributed to long turnaround times for results (up to 2–3 weeks), which hampered timely decision-making on isolation, contact tracing, and medical care, among other issues.

Eventually, the DRC rapidly expanded testing capacity by decentralizing testing sites and adopting RDTs and GeneXpert testing. Starting in June 2020, when INRB was the country’s only testing site, testing services were decentralized beyond Kinshasa. By December 2020, there were a total of 25 testing labs, covering 14 of the DRC’s 26 provinces, and daily testing capacity had increased to about 2,000 PCR tests per day. By June 2021, the total number of testing labs had increased to 31, covering 17 of the 26 provinces (testing labs had been concentrated in the Kinshasa province). The use of RDTs had also expanded, accounting for about 20 percent of all tests conducted in the DRC.

The DRC also improved access to COVID-19 testing by training more health care workers to provide tests and by introducing RDTs in June 2020, and GeneXpert testing at points of care in July 2020, which increased testing capacity by about 400–600 tests per day. Testing also was provided free of charge, except for some groups, such as travelers.

Despite these measures, access to COVID-19 testing remained limited, with only six percent of the DRC’s health facilities providing it. Other persistent barriers to test access included limited test kit availability, long turnaround times, poor road conditions, and long distances to testing facilities. Demand for testing was also suboptimal, frequently due to widespread misinformation. For instance, many people believed that COVID-19 did not exist.

SAMPLE DELIVERY

Between March 2020 and July 2020, the turnaround time from specimen collection to results return improved from 2–3 weeks to 24–48 hours in provinces with a testing site. The decentralization of testing services contributed to this improved turnaround time. Provinces without a testing site still transported their samples by air to a lab in Kinshasa, with support from WHO and the U.S. Centers for Disease Control and Prevention. Ninety-five percent of samples from these provinces arrived at the testing lab in good condition due to a strong quality assurance system. Still, median turnaround time was seven days, which caused delays in decision-making, including on the isolation of confirmed cases and contact tracing.

RESULTS COMMUNICATION

Lab results were returned electronically via phone calls, SMS texts, or email notifications. Hard copies were also shared with health care providers and tested individuals.

What was the DRC’s Surveillance Strategy? How did it use Data to Guide Public Health Actions?

The DRC’s COVID-19 surveillance strategy was risk-based—in the context of a limited supply of tests, it targeted symptomatic alerts, high-risk contacts, travelers, and health care workers. It also provided testing to those who were symptomatic. The DRC leveraged its expertise with EVD to develop the country’s surveillance strategy and in Kinshasa, all 35 health zone officials were paired with someone experienced in EVD outbreaks.

In general, the DRC’s surveillance strategies suffered from a lack of resources. For example, health care providers went on strike from July to August 2020, after the government failed to pay them for the previous three months. Surveillance suffered during this period, as health care providers had played a critical role in alert management, contact tracing and investigation. They returned to work, but by January 2021, their salaries were five months in arrears. EVD outbreaks between June and September 2020, and again in February 2021, further limited funding and capacity for the DRC’s COVID-19 response. Additionally, the country was dependent on financial support from international partners, and areas those partners did not support too often went unfunded.

Given the resource constraints and challenges related to pervasive COVID-19 misinformation in the DRC (including limited risk communication around disease prevalence), surveillance activities less relevant to active case detection, such as serology and genomic surveillance, were also less common. For instance, the DRC only began sequencing to identify variants once travelers from the DRC were banned by other countries.¹⁷

Table: DRC’s Surveillance Activities by Level

Data source for table: University of Kinshasa 

Level	Surveillance activities
Community and health zone	Active case search from CHWs Hotline for case reporting from citizens Facility-based reporting Investigate reported cases Contact tracing Home follow-ups for travelers
Province	Intermediate level Supporting and mentoring of HZ staff Receive HZ activity reports, analyze them and send them to the central level
National	Central hotlines for case reporting (109 and 110) Point of entry screenings Genetic sequencing Analysis and decision-making Elaboration of guidelines Follow up and training

Surveillance Modalities

COMMUNITY-BASED SURVEILLANCE

Community health workers conducted community surveillance through active case searches and the national COVID-19 hotline, which by November 2020, managed nearly 3,000 calls per day. Community health workers were involved in contact tracing and supported outreach in each health zone.

COMMUNITY SURVEYS

Two seroprevalence surveys have been conducted in Kinshasa: one in October 2020 by INRB, and another in April 2021 by WHO. For the first survey, a total of 1233 participants from 292 households were included (mean age was 32.4 years and 61.2 percent were women). The overall weighted, age-standardized SARS-CoV-2 seroprevalence was 16.6 percent. Prevalence was higher among participants over the age of 40.¹⁸ As of June 2021, the results of the second serological survey are yet to be published.

CONTACT TRACING

Initially, contact tracing (performed by volunteers) was centralized at the national level in Kinshasa, the epicenter of the DRC epidemic. High-priority groups for contact tracing included travelers from countries affected by COVID- 19, contacts of confirmed cases, and health care personnel who had been in contact with a confirmed COVID-19 case—a group that studies show is particularly at risk of infection.¹⁹ In May 2020, due to the rapid increase in COVID-19 cases and the spread to other provinces, contact tracing was decentralized to the provincial level and organized by the health zone management team. Directorate of Epidemiological Surveillance experts trained health zone management teams, first in Kinshasa and then in Kongo Central, Haut-Katanga, and North Kivu. The health zone management teams then cascaded training to community health workers in these provinces.

POINT OF ENTRY SURVEILLANCE

Even before the DRC reported its first case of COVID-19, the country’s health officials began to track travelers at points of entry in an organized and systematic way—something they had not done in previous epidemics. All arriving and departing travelers were required to have their temperature taken and complete a paper identification form that included contact information, signs or symptoms present, and history of participation in mass events or travel to a high-risk area in the previous 14 days. Officers of the national border hygiene program entered all this information in an Excel file; then, the aggregated data were transmitted to different health zones for contact tracing, investigation, and testing, if necessary.

The large points of entry were equipped with computers to enable data entry and analysis, but there were not enough health care personnel at these points of entry. Additionally, given the large number of travelers in and out of the DRC every day—rapid data management was a challenge. The four provinces most affected by COVID-19 (Kinshasa, Kongo Central, Haut-Katanga, and North Kivu) have multiple points of entry, some of which were poorly equipped due to limited human resources and surveillance kits (including computers, tablets, and data collection and reporting tools). This allowed some cases to enter the country without being detected.

POSTMORTEM SURVEILLANCE

Postmortem surveillance was used to determine the cause of death of those who had symptoms consistent with COVID-19 or other respiratory illnesses. However, only one province (North Kivu) implemented mandatory postmortem testing to those indicated. Additionally, there was often resistance from surviving family members who may not have believed in the existence of COVID-19 and declined postmortem testing. Though excess deaths were tracked to assess the COVID-19 pandemic’s impact on the health system more generally, reporting was suboptimal.

Data Management, Reporting, and Use

DATA USE, STORAGE, AND TECHNOLOGIES

At the onset of the COVID-19 pandemic in the DRC, epidemiological reporting—including notification of suspected cases, case investigation alerts, contact tracing, delivery and reporting of lab results—was done mostly using paper forms. These included the alert, investigation, contact tracing, and passenger tracking forms. Health facilities used a paper-based template to report to the health zone every week and to the central level every month.

In June 2020, with technical assistance from the health systems firm Bluesquare, some health zones piloted digital reporting to replace the paper-based reporting in use under the Integrated Disease Surveillance and Response strategy. Building from the experience of Bluesquare in several other countries, the objective was to incorporate COVID-19 indicators into DHIS2 and improve the timeliness of case reporting.²⁰ In addition, WHO started piloting the Early Warning, Alert and Response System (EWARS) in some health zones. However, as of June 2021, the Bluesquare and WHO systems were not fully integrated.

Early Warning, Alert and Response System (EWARS)	Bluesquare digital reporting system
Implemented in five health zones in Kinshasa with WHO support Collects data with tablets Not interoperable with DHIS2 Data are housed in WHO server and analyzed and reported only by WHO	Being piloted in ten health zones other than those where WHO is implementing EWARS; six are funded by PATH and four by IMA World Health Collects data with tablets using an Open Data Kit (ODK) system compatible with DHIS2 User-friendly electronic forms that mirror paper versions; offline functionality enables widespread use in contexts with low connectivity

The health care infrastructure was also digitized in other ways. Since March 2020, the Technical Secretariat for the COVID-19 response has produced a daily electronic COVID-19 epidemiological bulletin, which provides updates on key indicators, including confirmed cases, deaths, and their locations within the DRC.²¹ Digitization of lab data collection and reporting had begun prior to COVID-19 in response to EVD outbreaks, though this work was not complete (lab data are not integrated into DHIS2); paper forms (such as reports from community health workers to the central nurse) still played a critical role in reporting data up the health system. Limited internet and a lack of tablets led to digital reporting that was incomplete, delayed, or missing data.

With support from PATH, the Directorate of Epidemiological Surveillance set up a WhatsApp number that anyone could use to get information or ask questions about COVID-19 in the DRC. It offered automatic prompts on six main subjects:

• The epidemiological situation
• How to protect yourself
• Answers to your questions
• Advice for travelers
• News
• Sharing of the WhatsApp number

Likewise, a real-time communication tool known as mHero was deployed to improve communication between health authorities at the national Ministry of Health and frontline health care workers in Kinshasa. On a weekly basis, the tool collected data from tens of thousands of workers on safety measures, including the availability of personal protective equipment.

How did the DRC Coordinate its Testing & Surveillance Efforts?

Following the declaration of a COVID-19 outbreak in the DRC on March 10, 2020, health officials adapted the existing incident management structure from EVD outbreaks for COVID-19, where an incident manager liaised between operational-level and higher-level personnel. The DRC’s president set up a Multisectoral Response Committee, headed by the Prime Minister, that included all relevant ministries (Finance, Social Affairs, Foreign Affairs, and others). The Ministry of Health was charged with coordinating the COVID-19 response, and was assisted by a Technical Secretariat which, in turn, was assisted by an Advisory Committee whose members included representatives from the private, nongovernmental organization, and academic sectors.²² There were four primary response areas, each with subcommittees (such as surveillance or simulation exercises). Each group met at least once per week.

This response structure reflected coordinated partnerships and effective engagement across multiple levels of government. However, parallel coordination structures (especially between new structures developed for COVID-19 and existing structures) led to inefficiencies. These were exacerbated by limited budget allocations for outbreak preparedness and planning, and weak strategic coordination across national and subnational lab networks.

What are Key Lessons from the DRC’s Response to COVID-19?

Because the DRC had a great deal of experience with surveillance for other infectious diseases, it had preexisting tools and systems it could leverage for its COVID-19 response. However, a lack of resources and supplies, and communication breakdowns at the local level continued to limit the country’s ability to roll out comprehensive testing and surveillance solutions to the entire population.

Conclusion

The DRC rapidly developed its COVID-19 response by leveraging previous outbreak experience (as it had with EVD) and preexisting surveillance and lab systems. It ramped up and decentralized testing capacity to improve access and turnaround time.²³ However, limited resources and reliance on donors led to a testing strategy that focused on high-risk groups, which resulted in the under detection of cases. Additional surveillance methods, such as seroprevalence surveys and postmortem surveillance, were also limited due to resource constraints. Adoption of RDTs in June 2020 improved access to testing, but availability remained inadequate.²⁴ Technology developments (such as EWARS and Bluesquare) to support surveillance and testing have not been brought to scale due to inadequate electricity services, internet connectivity challenges, and resource constraints.

While the DRC has experienced many challenges with its COVID-19 response, there are lessons that can be learned from how the country addressed these challenges. Documenting the country’s response may also inform improvements for future preparedness and response efforts.

AUTHORS Alice Namale, Mala Ali Mapatano, Marc Bosonkie, Rhoda K. Wanyenze