SARS-CoV-2 serosurveys in low-income and middle-income countries
Authors: Jean Claude Mugunga, Kartik Tyagi, Daniel Bernal-Serrano, Nidia Correa, Matias Iberico, Frederick Kateera, Fernet Leandre, Megan Murray, Jean Christophe Dimitri Suffrin, Bethany Hedt-Gauthier
Journal: The Lancet (2021)

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) serosurveys provide crucial information on previous SARS-CoV-2 infections in communities.1Peeling RW Wedderburn CJ Garcia PJ et al.Serology testing in the COVID-19 pandemic response.Lancet Infect Dis. 2020; 20: e245-e249Summary Full Text Full Text PDF PubMed Scopus (226) Google Scholar These surveys are particularly useful in low-income and middle-income countries (LMICs), where limited testing capacity inhibits the ability to monitor COVID-19 burden through routine care and contact tracing.2Kavanagh MM Erondu NA Tomori O et al.Access to lifesaving medical resources for African countries: COVID-19 testing and response, ethics, and politics.Lancet. 2020; 395: 1735-1738Summary Full Text Full Text PDF PubMed Scopus (107) Google Scholar We represent a global group of clinical, programmatic, and research leaders that, through long-term collaborations between Partners In Health and national ministries of health, are supporting COVID-19 response data collection and analysis needs in eight countries. SARS-CoV-2 serosurveys are included in the broad set of activities that we are supporting; however, as our teams began developing core technical documents on the design and analysis of serosurveys, we realised that there were divergent opinions on individual protocols within these serosurveillance activities, specifically as to whether or not to return SARS-CoV-2 antibody test results to the individual participating in the serosurvey activity. There are many reasons why this topic is debatable, and we highlight some of our key considerations to help other teams designing SARS-CoV-2 serosurveys in LMICs to think through these issues, and to generate a broader discussion as to the pertinence of returning SARS-CoV-2 antibody test results when done as part of serosurveys in different countries. As a starting point, we compiled experiences from others implementing SARS-CoV-2 serosurveys within Latin America, the Caribbean, and Africa—the regions where our programmes operate. In the most recent search (completed on Dec 10, 2020), we identified a limited number of serosurveys that were either published works or preprints, and a handful more through combing news and social media or through our personal networks.3Silveira M Barros A Horta B et al.Repeated population-based surveys of antibodies against SARS-CoV-2 in Southern Brazil.medRxiv. 2020; (published online May 1.) (preprint)https://doi.org/10.1101/2020.05.01.20087205PubMed Google Scholar, 4Hallal P Hartwig F Horta B et al.Remarkable variability in SARS-CoV-2 antibodies across Brazilian regions: nationwide serological household survey in 27 states.medRxiv. 2020; (published online May 30.) (preprint)https://doi.org/10.1101/2020.05.30.20117531Google Scholar, 5Gomes CC Cerutti C Zandonade E et al.A population-based study of the prevalence of COVID-19 infection in Espirito Santo, Brazil: methodology and results of the first stage.medRxiv. 2020; (published online June 13.) (preprint)https://doi.org/10.1101/2020.06.13.20130559PubMed Google Scholar, 6Tess BH Granato CFH Alves MCGP et al.SARS-CoV-2 seroprevalence in the municipality of Sao Paulo, Brazil, ten weeks after the first reported case.medRxiv. 2020; (published online June 29.) (preprint)https://doi.org/10.1101/2020.06.29.20142331Google Scholar, 7Kempen JH Abashawl A Kinfemichael H et al.SARS CoV-2 Serosurvey in Addis Ababa, Ethiopia.medRxiv. 2020; (published online June 23.) (preprint)https://doi.org/10.1101/2020.06.23.20137521Google Scholar, 8Picon RV Carreno I Anjos da Silva A et al.Coronavirus disease 2019 population-based prevalence, risk factors, hospitalization, and fatality rates in southern Brazil.Int J Infect Dis. 2020; 100: 402-410Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 9Shakiba M Hashemi Nazari SS Mehrabian F Rezvani SM Ghasempour Z Heidarzadeh A Seroprevalence of COVID-19 virus infection in Guilan province, Iran.medRxiv. 2020; (published online April 26.) (preprint)https://doi.org/10.1101/2020.04.26.20079244Google Scholar, 10Chibwana MG Jere KC Kamng'ona R et al.High SARS-CoV-2 seroprevalence in health care workers but relatively low numbers of deaths in urban Malawi.Wellcome Open Res. 2020; 5: 199Crossref Google Scholar, 11Uyoga S Adetifa IMO Karanja HK et al.Seroprevalence of anti-SARS-CoV-2 IgG antibodies in Kenyan blood donors.medRxiv. 2020; (published online July 27.) (preprint)https://doi.org/10.1101/2020.07.27.20162693Google Scholar Of the 16 serosurveys we identified, only two had documentation of individual protocols and so we contacted the study leads for more details. We received replies from eight study leads, of which six reported that all sampled individuals received the results of their antibody tests. These individuals noted the right of participants to know, individual study institutional review boards protocols, as well as the importance of being open and transparent with participants as the central reasons for providing these results to the survey participants, informing our discussion regarding the return of results. For two studies, results were not automatically returned, although in the case of the study from Malawi, results were available to individuals upon request. The two studies that had documentation on individual protocols followed up positive individuals with either immediate quarantine in a hotel or a COVID-19 treatment centre, in the case of Togo, or testing of all adult household contacts immediately or the next day, in the case of southern Brazil. Even when considering the experiences from the projects mentioned here, our group continued to discuss the pros and cons of returning test results to individual participants without reaching consensus. Noting that countries might have different recommendations, and that even within countries, recommendations might vary based on the target population. Those in favour of returning results focused largely on the rights of individuals to know the outcomes of their tests and the need to respect individuals' autonomy. Some country sites are considering result-specific interventions, such as follow-up testing or extending testing to household contacts, in which case results must be returned to individuals to proceed. Those against returning results focused on the poor test properties, particularly the risk of false positives early in the epidemic, and the lack of a full understanding of SARS-CoV-2 infection dynamics. Knowledge is still unfolding in relation to how previous infection confers immunity and how long immune protection might last. Further, some individuals expressed fear about the implication of results being misinterpreted—eg, requiring quarantine for seropositive individuals, or positive results leading to potential stigma and discrimination. As we discussed returning results to individuals, we identified other key factors that should be considered and discussed in tandem for SARS-CoV-2 serosurveys. National institutional review boards should be consulted early as these institutions might have clear guidance on if and how such results should be communicated to participants. Regardless of the return of results, community sensitisation will be key for gaining trust and buy-in for participants, and if results are returned, this sensitisation can prevent issues surrounding unnecessary stigma. Staff must be trained, not only on safe and high-quality testing procedures, but also on ensuring confidentiality of test results. Pretest counselling accompanied by context-specific support materials will be important for individuals participating so that they better understand COVID-19 risks, the antibody testing process, and COVID-19 risk factors. If returning results, post-test counselling will be equally important to ensure patients correctly interpret the results and complete the appropriate follow-up activities. Finally, country sites should continue toward validating the antibody tests for their specific setting to ensure that the test properties are known, which is important for both interpreting individual test results and for adjusting overall prevalence estimates.12Diggle PJ Estimating prevalence using an imperfect test.Epidemiol Res Int. 2011; 2011: 1-5Crossref Google Scholar Our discussions around returning test results to individuals participating in SARS-CoV-2 serosurveys evoked differing opinions based on a range of ways of approaching the issue, and have as of yet not led to a resolution. We hope this Comment will bring this conversation to a broader community, encouraging global health regulating bodies to develop related guidance. Notably, there was no discussion or explicit recommendations on individual reporting of serosurvey results in the latest WHO COVID-19 surveillance protocols for health-care workers. As stakeholders in LMICs implement serosurveys, we advise these teams to make full protocols, including the details of individual testing and public support of decisions. We believe that it is important to capture the participants' experiences with SARS-CoV-2 serosurveys, and their desire to know the antibody test results, as their views should be central to the discussion moving forward. We declare no competing interests.