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Can't Get Tested for Covid-19? Maybe You're in the Wrong Country

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Decisions and blunders made months ago have caused testing disparities worldwide. The science, it turns out, was the easy part.

Scientists around the world were waiting at their computers in early January when China released the coronavirus genetic code, the blueprint for creating tests and vaccines. Within days, labs from Hong Kong to Berlin had designed tests and shared their research with others.

Within about two weeks, Australia had its own tests, and even citizens in the most far-flung regions of the country could be tested. Laboratories in Singapore and South Korea ramped up test kit production and ordered extra supplies. That quick work allowed them to test hundreds of thousands of people, isolate the sick and — so far, at least — contain the spread of the disease.

By contrast, anxious citizens in the United States and many parts of Western Europe have endured byzantine delays, or have been denied testing altogether. As the coronavirus pandemic shuts down world capitals and paralyzes entire economies, political leaders are rushing to make testing more widely available.

But experts say that the decisive moment, when aggressive testing might have allowed officials to stay ahead of the disease, passed more than a month ago. It was not a question of science. Researchers say a viral test is relatively easy to develop. Rather, scientists say, the chasm between the testing haves and have-nots reflects politics, public health strategies and, in some cases, blunders.

The world may be paying for those missteps right now. Testing is central to the effort to fight the spread of the virus. Countries that test widely can isolate infected people and prevent or slow new infections. Without early and widespread testing, health officials and policymakers will be flying blind, epidemiologists say.

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“Y​ou cannot fight a fire blindfolded,” said Tedros Adhanom Ghebreyesus, W.H.O.’s director general. “And we cannot stop this pandemic​ i​f we don’t know who is infected.”

But testing has been inconsistent in what has been a patchwork response to the epidemic worldwide.

Some countries, like France, did not have a strategy that centered on testing to map the advance of the virus. Testing in Italy has been plagued by political squabbles. The United Kingdom developed tests but decided not to use them widely, as Singapore and South Korea had done. Other countries were caught off guard by shortages of testing chemicals.

As the virus reached into the United States in late January, President Trump and his administration spent weeks downplaying the potential for an outbreak. The Centers for Disease Control opted to develop its own test rather than rely on private laboratories or the World Health Organization.

The outbreak quickly outpaced Mr. Trump’s predictions, and the C.D.C.’s test kits turned out to be flawed, leaving the United States far behind other parts of the world — both technically and politically.

In that same period, Singapore was setting up health screenings at airports, issuing work-from-home guidelines and releasing plans to monitor travelers returning from abroad. Independent labs in Korea were rushing their tests out the door.

“They were ready, and they just churned out the kits,” said Dr. Jerome Kim, of the International Vaccine Institute in Seoul.

Today, the epicenter of the outbreak is Europe and experts say the wave is only starting to hit the United States. Faced with a growing number of cases and limited test kits, many countries have tightened restrictions on who gets tested. In Germany, where the first approved test was developed, only doctors can prescribe one. In France and Belgium, only severely sick patients get tested.

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In Britain, as in many other countries, the virus is circulating so quickly that it is no longer possible to test people and investigate whom they may have infected, said David McCoy, a public health professor at Queen Mary University in London. Nearly 100 people have died from the virus there. Testing is still valuable in helping scientists understand the epidemiology of the disease, he said.

“The window of opportunity to contain the epidemic has now shut,” Mr. McCoy said.

‘This Could Be a Problem’

From the beginning, some countries showed greater urgency than others and were more nimble in their response.

Australia, Korea and Singapore turned to networks of public and private laboratories to develop tests. On Feb. 4, the South Korean government granted fast-track approval for a company’s coronavirus test and began shipping kits. A second company was approved a week later. Two more soon followed.

Australian labs designed a generic test in early January, then refined it after receiving the genome. “We were anticipating early on that we could see cases, that this could be a problem,” said Dr. Jen Kok, a government virologist in New South Wales, Australia, a region where more than 33,000 people have been tested so far.

The United States and Britain favored a centralized approach. Britain initially assigned a single lab in north London to perform the tests but, a month later, began allowing other labs to do the same.

The C.D.C. had to reverse course, too. After its homegrown test proved faulty, it cost the country valuable time. The Trump administration then had to change tactics, urging outside labs and manufacturers to help make a million tests available.

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Labs that moved quickly had an advantage. They purchased extra testing products, known as reagents, that extract viral RNA from nose or throat swab samples. Those reagents are now in short supply.

“It’s the way we do things here,” said Dr. David Speers, the top microbiologist at PathWest Laboratory Medicine, the government laboratory in Western Australia. “We always try to plan ahead.”

Technical speed and laboratory organization, though, do not explain everything. The availability of testing — at least in some countries — also reflects policy.

When Australia identified its first coronavirus patient in late January, political leaders made clear that testing would be widespread. “We’re testing people,” Dr. Kerry Chant, the top public health official in New South Wales, said on Jan. 30. “We’re asking people to come forward, and I want to acknowledge the fact that we have had so many people come forward for testing.”

Even before the virus began spreading in Singapore, the prime minister, Lee Hsien Loong reminded the public about the 2003 SARS outbreak and said he planned to overreact to the coronavirus. “We have built up our institutions, our plans, our facilities, our stockpiles, our people, our training,” he said on Jan. 31. “Because we knew that one day something like that would happen again.”

South Korea opened nearly 600 testing clinics, including dozens of drive-through stations. More than 250,000 people have been tested — far more than any other country that has released data.

The country has largely contained its outbreak to the southeast city of Daegu. Most cases are linked to a cluster around the Shincheonji Church of Jesus.

“Korea’s approach was: Test everybody,” Dr. Kim said. “Anybody who needs a test should get tested.”

The United States, along with countries in Western Europe, chose a different strategy and tone. While Singapore warned that infections were certain to increase, Mr. Trump predicted it would disappear within weeks.

In late January, French officials were hesitant to activate emergency protocols because they did not believe that the epidemic was as serious as the 2009 H1N1 outbreak.

“We have three cases in France and they are not that severe,” Dr. Patrick Pelloux, of the country’s emergency medical services, said Jan. 25. “It’s an epidemic that is under control.”

France says that it is able to test 2,500 cases daily, and health officials said earlier this week that more than 40,000 people had been tested. The United States has run about 25,000 tests. Neither country has contained the virus or tested aggressively for it. Korea and Singapore have so far been able to do both.

“We were not just looking at having a very good diagnostics test. That’s kind of a given. You can’t do anything without that,” said Dr. Sidney Yee, the chief executive of Singapore’s Diagnostics Development Hub. “We were also looking at getting people prepared and getting accurate messages out.”

Nicolas Locker, a professor of virology at the University of Surrey in Britain, said national leaders set the tone. “What you’re seeing today is the impact of those earlier comments, and that earlier attitude,” Dr. Locker said.

Incorrect Assumptions

Testing can be as much a political issue as a scientific one.

Italy, the site of the biggest outbreak outside China, is a prime example. At first, regional authorities in the north tested widely and tried to trace contacts with sick people. But the national government in Rome objected, saying there was no need to test people who did not exhibit symptoms.

“Someone said we’re testing too many people and this is why we have such a huge number. That is not true,” Giovanni Rezza, director of the department of infectious diseases at the Italian National Institute of Health.

Under pressure, the regional governments began testing only patients who exhibited symptoms. Politicians and scientists continue to debate those protocols, Dr. Rezza said. Still, the country has managed to test more than 182,000 people.

Britain was one of the first to develop coronavirus diagnostic kits but made a decision not to test widely. The government’s strategy initially focused on slowing the contagion rather than stopping it. The government, though, severely underestimated the potential scope of the epidemic, according to a study published on Monday.

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Prime Minister Boris Johnson’s government recently reversed its strategy and decided to widen testing. Mr. Johnson told Parliament on Wednesday that his government will have the ability to conduct 25,000 tests a day.

But raw numbers ignore the effect of timing. South Korea deployed its tests early and alongside other approaches, including some that European populations might resist. A government app monitored people to ensure they remained quarantined. Police officers used surveillance camera footage, phone data and credit card records to recreate the movements of new patients and identify potential contacts.

Kim Gang-lip, a South Korean vice health minister, said the contagiousness of the disease and its rapid spread demanded a new approach. “Such characteristics of the virus render the traditional response, which emphasizes lockdown and isolation, ineffective,” he said.

A New Testing Reality

Lockdown and isolation are a reality today for tens of millions of people.

Italy is at a standstill. Europe has all but shut its borders. President Emmanuel Macron of France told people to stay at home for 15 days and ordered the army to transport the sick to hospitals. Mr. Trump recommended against all but the smallest gatherings.

With no treatment for the disease, many countries are telling sick people to stay home unless they become seriously ill. Hospitals cannot afford to be overwhelmed by nervous people asking for tests.

But patients who self-quarantine likely won’t ever be tested, making it difficult to know the true scope of the disease. And as the disease spreads, the practicality of testing declines, as does its value.

“Testing of contacts, I believe, will be totally out of control very soon,” said Manfred Green, an epidemiologist with the University of Haifa in Israel.

Australian officials say they, too, worry about wasting tests on the merely worried. They recently adjusted testing protocols, but remain aggressive. Anyone who has recently been out of the country and so much as spikes a fever will likely be tested. “We are still in the containment phase,” said Dr. Kok. “We’re testing really widely.”

Source: www.nytimes.com

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CMLF News Issue #7
27th January 2016