Dr Janice Thompson and Sinéad McMurray
This article is based on information extracted from the RaISe briefing paper: Testing for Sars-CoV-2 in the UK; and the Use of Testing and Contact Tracing in Selected Countries (published 4 May 2020).
For wider context, this article is best read in conjunction with that paper, which focused on reviewing the approaches to testing, contact tracing and related measures taken in NI, as part of the UK pandemic response. It also looked at a number of selected countries which have taken a range of different approaches in this regard. The paper highlighted the importance of both timely testing and contact tracing to drive suppression of transmission of the virus to a low-level, to enable or maintain parts of economic and social life.
Context
Countries across the world are at different stages of dealing with the COVID-19 pandemic. By 13 March 2020, the World Health Organization (WHO) called for intensified action and stressed that countries should take a comprehensive approach:
Not testing alone, not contact tracing alone. Not quarantine alone. Not social distancing alone. Do it all. Find, isolate, test and treat every case…
By then, governments across the world were taking various approaches. Some based their response on decreasing contact between people to slow transmission of the virus; for example, some closed schools and imposed social distancing measures/’lockdowns’ and tested those who were seriously ill for SARS-CoV-2 (the virus that causes the illness COVID-19). Others, but not the UK, focused on more widespread testing, contact tracing and quarantining.
The WHO has consistently called for extensive testing of all suspected cases so that confirmed cases are isolated and receive care, and their close contacts are rapidly identified so that they can also self-isolate/be quarantined and monitored. It recently highlighted that in countries where there has been early implementation of that approach, for example South Korea, the spread of COVID-19 has been suppressed below the threshold at which health systems become unable to prevent excess mortality.
However, in places where community transmission has led to outbreaks with near exponential growth (for example in Italy, Spain, UK), countries were forced to introduce widespread physical distancing measures and movement restrictions (‘lockdown’) in order to slow the spread. For such countries, there is now an urgent need to plan for a phased transition away from such restrictions to enable the suppression of transmission of the virus to a low-level, whilst enabling the resumption of parts of economic and social life.
Diagnostic testing for SARS-CoV-2 and post-infection antibody testing
The diagnostic test involves molecular diagnosis using ‘real-time RT-PCR (RdRp gene) assay’ with swab samples taken from the nose, throat and deeper respiratory tract. Laboratory technicians then look for genetic sequences specific to the virus in the sample. In Northern Ireland (NI), the Health Minister, Robin Swann MLA, recently stated that he is seeking to increase diagnostic testing capacity working with laboratories outside of the traditional health and care sector in NI and to investigate the scope for manufacturing the necessary reagents.
Post-infection, the antibody test works by looking for signs of immunity, by using a drop of the person’s blood. In the UK, a reliable laboratory-based antibody test is in use at the Public Health England (PHE) laboratory at Porton Down, but it is currently reserved to estimate population-level immunity and not to give individuals information about their antibody status. Recent progress in this area has been rapid in sourcing an antibody test for more widespread use in the UK. Media reports on 4 May 2020 stated that a first widespread antibody test could soon be approved for use in the UK by PHE. Such tests are already being used in other countries. For example, Germany is the first European country to carry out a large-scale antibody testing study. It is hoped that this will provide more information on how many people have antibodies, at what levels, and what protection they offer against the virus.
Review of approaches taken in other countries
The table below summarises a substantial amount of information taken from the full RaISe paper on the approaches being currently taken to ‘lockdowns’, social distancing, testing and contact tracing in a selection of countries. The paper should be consulted for the relevant references. It provides significantly more detail on each country’s approaches, its measures, and also outlines the ‘evolution’ of the pandemic response in NI (as part of the UK-wide response).
Countries include the Republic of Ireland, as NI’s nearest neighbour, and also New Zealand and South Korea who have managed to control community transmission of the virus through rigorous testing and tracing. South Korea (and other Asian countries) had a head start on contact tracing plans through its response to Middle East Respiratory Syndrome (MERS) in 2015. Sweden, considered an outlier with regard to its ‘light touch’ to managing the virus, is considered alongside Germany whose rigorous testing and tracing approach is being highlighted as a key reason for its low mortality rate. France, Spain and Italy all received significant domestic criticism for their testing regimens in the early stages of the pandemic but now have a renewed focus on testing as a key part of their exit strategies.
| What social distancing and movement restrictions are in place? | What are the current testing strategies? | Who is being prioritised for testing? | How are close contacts being traced and managed? | |
|
Northern Ireland |
‘Lockdown’ enacted and enforceable in line with UK-wide response.
Supported by legislation:
|
Short term:
Expanded diagnostic testing by broadening the categories of workers/ patients approved for testing. Expanding testing capacity: Consortium between QUB, UU, C-TRIC[1], and AFBI[2] to scale up diagnostic testing, including local production of reagents. Wider surveillance testing using samples from:
Medium to Long term:
|
Currently:
Healthcare workers. Key workers who are self-isolating and /or their family members who have symptoms including those working in:
Staff and patients in care homes, specifically:
Those admitted to Hospital for Emergency and Elective care. |
Early ‘containment phase’, small numbers of cases who became unwell after travel to affected areas were tested and their contacts traced and tested to establish if such transmission had occurred. This ceased once ‘delay phase’ started in mid-March.
Pilot led by Public Health Agency to inform NI-wide contact tracing and management system as part of UK-wide plans going forward – to support easing of ‘lockdown’. Initial focus on priority groups where clusters may be present, starting with care homes. There are UK plans to introduce a contact tracing ‘app’ but the type/technology has not been confirmed. Currently in trial on Isle of Wight. NI Health Minister calling for any contact tracing ‘apps’ used in the UK to be the same or technically compatible so that information can be shared.
|
|
Republic of Ireland |
Similar to UK, ‘lockdown’ enacted and enforceable:
Supported by legislation: Phase one of lifting the restrictions begins 18 May. |
Short term:
Priority still being given to those with one symptom of COVID-19 and belonging to a priority group (see next column) Expansion of diagnostic testing: Consideration currently being given to removal of membership of a priority group as grounds for testing. Medium to long Term: Develop and expand antibody testing capacity (currently not available) |
Priority groups for testing:
|
Extensive contact tracing service in operation since 10th March:
Future plans:
|
|
South Korea
|
Moderate approach focused on:
|
Continuation of mass diagnostic testing through:
Expand antibody testing – began in early April and currently rolling out the programme on a larger scale.
|
A person can be tested if they:
People who do not belong to those categories but wish to be tested are charged for test but reimbursed if the result is positive. |
Ongoing contact tracing (manual and ICT methods) and quarantine programme using:
|
|
New Zealand |
Early enactment of strict four stage ‘lockdown’:
Have now downgraded to phase 3 of ‘lockdown’ with some lifting of restrictions. |
Short term:
Comprehensive diagnostic testing programme of priority groups to continue. In the process of expanding programme to include broader based community testing by loosening categories of priority groups. Medium Term: Will consider antibody testing when reliable test are confirmed:
|
Priority groups include:
|
Comprehensive manual tracing programme using National Close Contact Tracing Service.
Close contacts will still be required to self-isolate until test results confirm status. Mandatory quarantining of returning citizens at border with movements traced using text message alerts. Consideration being given to development of ‘app’ to automate some tracing capabilities but not in immediate plans. |
|
Germany |
Strict Federal & State level social distancing measures:
Lifting of restrictions began 20th April. |
Short term:
Continue with mass diagnostic testing programme of priority groups through hospitals, GP practices and drive thru testing stations. Trialling antibody testing regionally and using a large nationwide sample – waiting for approval from German Ethics Council before expanding to nationwide programme. |
A person can be tested where they:
Block testing of medical staff in some hospitals (e.g. group of 10 samples only test individuals if group sample is positive). Government is currently limiting testing of asymptomatic people to ensure test supply. |
Rigorous contact tracing policy:
Every person who has come into contact with an infected patient in the previous two weeks is tracked down and tested. In the process of developing an ‘app’ tracing system to automate some of the contact tracing process. |
|
Sweden |
Minimal approach:
|
In the process of expanding diagnostic testing by broadening categories of eligible groups – previously only those admitted to hospital were tested.
Antibody testing study has been carried out in Stockholm with plans to extend further. |
Groups being tested include:
|
Limited information on contact tracing and management system in Sweden is available – understood to be happening at a regional level with extent of tracing varying per region. |
|
France |
‘Lockdown’ measures comparable with other EU countries – Regulations in place.
France has outlined a ‘progressive and controlled’ exit strategy which will begin 11 May. |
Renewed focus on expanding diagnostic testing by:
Domestic media reporting that antibody testing will be rolled out in May/June. |
Categories originally included anyone showing symptoms who was also an:
Now anyone who displays symptoms and has been seen by a GP can be tested. |
Contact tracing being ramped up in line with testing:
|
| Spain | Full lockdown enacted with no outdoor activity outside of essential trips – Regulations in place. | Significantly expanding diagnostic testing with increase in production of local tests and procuring international equipment.
Conducting antibody testing using a sample of 36,000 households. |
Previously testing focused on those infected or suspected of having COVID-19.
Now there is a specific focus on testing asymptomatic carriers who are working in essential services. |
Extensive contact tracing system being established.
Voluntary isolation units for those who cannot isolate at home. Considering laws to enforce isolation where there is non-compliance. |
Conclusion
Differences in the policies in tackling the COVID-19 pandemic in various countries have been highlighted in the success or otherwise of minimising the transmission of the virus and the severity of the ‘lockdowns’ that have been required. South Korea, New Zealand and Germany have been highlighted as being very successful with their regimes of testing, followed by rigorous contact tracing and the quarantine/self-isolation of close contacts. However, New Zealand and Germany also have ‘lockdown’ policies; South Korea did not impose such draconian measures.
Until the end of March 2020, the majority of tests in the UK had been done on seriously ill hospital patients with symptoms of the virus. Throughout April, all regions of the UK have been ramping up diagnostic tests for healthcare and other key workers and vulnerable groups. This lack of testing compared to other countries appears largely to have been due to lack of capacity at the time. Only with the increasing capacity to test now available can the UK look to implement a substantial regime of testing and contact tracing in the hope of easing out of ‘lockdown’.
Experts, academics and scientists across the world are continually working on and publishing developments and proposals with regards to testing – both for improvements to the current tests for the virus and for antibody tests to check whether someone is likely to be immune having recovered from the virus. Both are key to moving forward:
- To determine as quickly as possible where and when new cases are emerging through diagnostic testing and contact tracing; and
- To pinpoint individuals who have already been infected through an antibody test.
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[1] Clinical Translational Research and Innovation Centre (C-TRIC ) on the Altnagelvin Hospital site in Derry/Londonderry.
[2] Agri-Food and Biosciences Institute.