We face a long struggle with Covid-19 that will last into 2021. Even if we control the current outbreak, fresh outbreaks will happen unless we completely close our borders for the rest of the year. We must think ahead to how we can maintain air links and continue to function in the face of a continuing threat of imported infections. Vastly increased capacity to test for Covid-19 has to be part of that. It will require a significant investment in equipment, supplies and manpower – billions of rupees, but the economic benefits will outweigh the costs.
The Ministry of Health (MOH) is probably making appropriate choices given the current situation, its available resources and the goals that it’s been given. But MOH typically considers only the health systems cost. The government needs to take a more strategic economy-wide perspective. It needs to act based on possible scenarios two to three months from now, and not the current situation. And it needs to act now. All testing equipment must be imported. The surge in demand around the world is stretching global supply chains to the limit – shortages and delivery times for testing machines and reagents are increasing. As in other areas of Covid-19 response, the cost of delay could be very expensive in terms of blood and treasure.
All governments so far that have had success in controlling Covid-19 have adopted aggressive testing policies. By success, I mean those that have either reversed major outbreaks or managed to slow or keep at a low level the increase in new cases. They include Singapore, Hong Kong, Korea, Taiwan and China, and possibly Germany in Europe. They have ramped up testing capacity early, increased access and avoided imposing restrictions on when doctors can order tests.
Capacity to test and restrictions on when doctors can order tests is closely linked. When countries, as happened notably in USA and Italy, have limited capacity, they use clinical guidelines to restrict when doctors can order tests.
Testing has two purposes: (i) it diagnoses new cases, and (ii) it provides data on how fast the virus is spreading.
Countries like Singapore show that aggressive and widespread testing significantly slows the spread of the virus. It increases the number of infected people who are detected – in many countries less than one in four cases are ever found, and it reduces the time it takes to put newly infected people into isolation. All this reduces the exposure of the community and slows the spread of the virus. For those of you who are technically inclined, Singapore’s testing policy reduced the R0.
A failure to test aggressively played a key role in the current outbreaks in the USA and Italy. It allowed infected people with no history of exposure to international travel or with no symptoms to transmit the virus undetected in the community for weeks, and it increased the size of the resulting outbreak. Korea on the other hand by aggressively testing hundreds of thousands of people in response to its first large outbreak has been able to stop the epidemic expanding and put it into reverse.
Testing also helps the health services in the critical job of finding people who have been in contact with infected cases and who may have been infected themselves. Singapore’s widely praised contact tracing effort is particularly effective in keeping cases low because it detects so many initial cases early, giving it a better chance of quickly finding others who may have been exposed. A key reason for this is that Singapore does not restrict testing to those with exposure to foreign travel. It encourages doctors to test anyone with flu-type symptoms or even on the basis of just suspicion, regardless of whether they have any risk factors. It also actively tests all patients with pneumonia and in ICUs and any deaths which might be infection related. Since last week, Singapore has also started airport testing of all arrivals with fever or other symptoms.
Singapore’s approach, which is similar to Hong Kong’s, is expensive. But the cost has to be balanced against the benefits. Singapore has kept its schools and universities open, it has not had to resort to lock-downs,
and it has not closed its airport. [22/03/20 update: Singapore will stop all arrivals by non-residents from midnight Monday 23 Mar – Having ridden out the first wave seeded by China, the failure of Western and other countries to take effective action has resulted in a new surge of cases in Singapore – 80% of its most recent cases have been imported.] This is despite its dense population and being far more exposed to imported cases than we are.
The same cost benefit of expanded testing would work for us. Our economy is highly dependent on international trade and lock downs cause billions in economic losses, far greater than the cost of any expanded testing policy. The shut down of business and shops also means less taxes go to the government. Each week that they continue, the government incurs billions in fiscal losses, money that it desperately needs to respond to the crisis. Much more aggressive testing policies would make it safer to relax travel restrictions and restrictions on normal life, would allow a higher level of economic activity during the next 12 months, and it would increase public confidence. It would also give us earlier warning of when a new outbreak requires stronger action, and allow us to minimize total lockdowns.
I am told that MOH has enough capacity to meet the current requests for tests. I also hear from doctors that they can sometimes order tests even when their patients don’t meet the official requirements, which is a good thing and typical of how our MOH flexibly adjusts to new challenges. MOH does not do a good job in sharing information, but the country including universities and private sector, may have capacity to do around 500 tests a day. New machines ordered by MOH and others may add several hundred tests a day. This compares with capacity for tens of thousands a day in places like Taiwan, Hong Kong and Singapore with similar or smaller populations.
This will not be enough if we want to maintain Sri Lanka’s status as a country with a low level epidemic and keep our ports, businesses, schools and universities open. Aggressive and high levels of testing will not only save lives, but it’s an investment that could give our economy a major comparative advantage in the next few months.
The government needs to take a broader perspective. It needs to find the money and push MOH to expand testing beyond immediate requirements. If immediate access to cash is the problem, special assistance is now available from the World Bank and other international agencies, and even commercial loans make sense given the pay-off.
Expanding test capacity means buying more machines and also reducing the time between testing and results by equipping more hospitals and investing in better machines that can produce results much faster. It may also need additional measures such as mobilizing the army to help with logistics and setting up a transport chain to move samples to labs. Having done that, we should move to a more aggressive testing approach including encouraging doctors to order tests on the basis of symptoms alone, testing more at risk people without symptoms, incorporating testing into our handling of airport arrivals, and increasing routine surveillance of high risk groups such as patients with pneumonia or flu symptoms.
*Thanks to Nilmini Wijemunige at IHP for the chart comparing testing rates in different countries.
**Please contact us if you have want to correct anything here or have additional information.