We, at IHP, have consistently advocated that the COVID response must include massive testing, not only to detect patients for treatment, but more importantly to break the spread of infection by reducing the time that hidden cases spend in the community.
On 6th April, IHP produced estimates that we need to be doing 6,000 tests/day ideally, and a minimum of 2,000/day if we could not do that. We shared that report with senior MOH officials, but we also made it publicly available though this blog. Countless medical experts outside MOH, including many of the most senior doctors in the island, plus the GMOA, have made similar calls.
Later that same day (6 April), we learnt that MOH experts themselves had come to the same conclusion. Prof Arjuna De Silva of Kelaniya University said live on Ada Derana TV that the epidemiologists at MOH Epidemiology Unit had concluded 5,000 tests/day were needed (26.08 mark in this video recording here). Another senior MOH official was on the same show, and not only did he emphasize the need to increase testing, he did not refute the claim about the Epidemiology Unit calculations. So we must assume MOH management had those numbers too.
At that point, we and others understood that to ramp up testing in this way could not happen over night. It needed systematic efforts to bring in new machines, sort out the logistical supply chains and ensure we had the lab and staff in place. So in our 6 April report we proposed taking actions then to achieve the increased numbers by 1 May. This did not happen, and the failure to ramp up testing contributed to the recent spike in cases.
Although testing numbers have increased to over 1,400 tests/day in the past week, this is still well short of the numbers needed to rapidly slow infection transmission in the community. Much of the recent increase is reactive and driven by the two large clusters that happened in late April. Unfortunately, there is a vicious circle that is resulting—inadequate testing results in more spread of the virus, which in turn increases case numbers and the need for tests to handle those.
This seems to be understood by MOH epidemiologists. On Friday (1 May), Epidemiology Unit experts informed the Minister that we may need to increase testing to 6,000/day (same as our estimate a month ago) if situation worsens.
If new cases push the need for tests higher, we will face serious capacity problems. Our lab experts working in MOH, university and private sector labs across the country are working long hours, many of them past midnight every day, and battling daily logistical problems to meet the current need. The risks of burn out and infection incidents resulting in lab staff having to be isolated are very real.
Initially, many of us thought that a key goal was to avoid cases reaching the level where our limited ICU capacity was overwhelmed. I increasingly think this is the wrong target. We need to keep case numbers much lower so that our testing capacity can cope.
Paradoxically, to keep future test numbers down, we need to test more now. It is only by expanding testing to undertake aggressive surveillance that we can increase the detection of hidden cases in the community and prevent future cases. And it is only by doing this that we can further slow the spread of the virus and keep overall infection numbers down.
This aggressive testing has been the key to controlling COVID in Hong Kong, Taiwan and others. To get there, we need more than just hard work by our lab staff. Specifically, we need new guidelines and policy from MOH to expand testing of general patients in the community, for example mandatory testing all patients with selected respiratory symptoms regardless of their travel history or exposure to the COVID cases. Right now this is not happening, and this is keeping test numbers artificially down. Until we can fix this, we face the risk that the virus will spread faster and result in greater pressure on our testing capacity.