ON 16 MARCH, just days after declaring Covid-19 a global pandemic, the head of the World Health Organisation (WHO) suggested that the world was not managing the crisis properly.
Likening the response until that point as like “fighting a fire blindfolded”, Dr Tedros Adhanom Ghebreyesus warned that social distancing measures and handwashing would not be enough to beat the virus alone.
“We have a simple message for all countries,” he said.
“Test, test, test. Test every suspected case. If they test positive, isolate them and find out who they have been in close contact with up to two days before they developed symptoms, and test those people too.”
In the weeks since, testing has become a central part of the conversation around Covid-19, with each nations’s capacity to test under almost as much scrutiny as its number of confirmed cases or deaths.
A large testing capacity is seen as giving health officials the best chance of detecting the spread of the virus in each country, which in turn allows decisions to be made about whether restrictions should be lifted.
The thinking is that strong testing and contact tracing regimes allow those who have contracted the virus to be isolated as soon as possible, preventing Covid-19 from being spread even further and easing the burden on health officials.
In Ireland, the Government has repeatedly said that an expanded testing regime is a key part of its strategy to gradually return to normal.
With current restrictions set to expire on 5 May, is our testing regime ready to allow them to be eased?
Ireland’s magic number
Over the last number of weeks, high-ranking officials have repeatedly pointed to a ‘magic number’ which they are targeting as one figure to examine when deciding whether to adjust the current restrictions.
Although it’s been the source of minor controversy, it’s generally agreed that Ireland needs to have the capacity to carry out 100,000 tests per week to allow a gradual return to normality to begin.
As of midnight on Monday, 153,054 tests had been carried out in Ireland, 41,470 of which were carried out since Tuesday last week.
Last night, director of the National Virus Reference Laboratory, Dr Cillian de Gascun told a media briefing that the target would be reached by the week beginning 18 May.
But the process isn’t just about sheer numbers. Last weekend, de Gascun also told RTÉ that the turnaround time for testing will also have to be shortened to a few days before restrictions are lifted.
Speaking to TheJournal.ie on this week’s episode of The Explainer, de Gascun said that as testing numbers scale up, the majority of results are expected to be generated within 24 to 36 hours, before contact tracing commenced.
“[If you are infected], we want to identify your contacts because they’ve had an opportunity to transmit the infection further,” he said.
“When we identify your symptoms, if you’re going to infect people, you will already have infected them. What we want to try and do is stop the next chain of transmission.”
Testing isn’t just about treating those who are infected: it’s about detecting the spread of the virus within the community and finding as many cases as possible.
There is an increasing amount of evidence which suggests that Covid-19 can be transmitted asymptomatically, which may be a significant contributor to the crisis.
That means that when a case is confirmed, all contacts of the individual who has the virus should ideally be tested, in case one of them has Covid-19 but isn’t showing symptoms.
Doing this allows clusters of transmission to be identified before people become symptomatic. And those who are asymptomatic can be isolated and prevented from spreading the virus (which is possible even if they don’t have symptoms).
This is also why the turnaround time for testing is important: any delay in test results has a knock on effect on contact tracing, meaning asymptomatic cases may be unknowingly spreading Covid-19 in the community.
All of this requires a large testing capacity. The more tests that can be carried out, the quicker those with the virus can get a result, and the faster those in contact with a positive case can be identified.
Without a good testing regime, a lifting of restrictions would likely lead to a surge in cases, placing significant pressure on GPs and hospitals, and leading to an overwhelming amount of deaths among vulnerable people.
As much as everyone would like a return to normality, nobody wants to see similar scenes to those in Bergamo in Italy last month, where army vehicles had to transport bodies to crematoriums because there were no more spaces in local cemeteries.
Case definition
While sufficient widespread testing is not possible, restrictions on movement and social gatherings must remain in place to pre-empt such a devastating surge – a process which has become known as ‘flattening the curve’.
But there has been some conflict in what health officials have been saying about the “test, test, test” strategy and what is actually the case.
NPHET, Health Minister Simon Harris and HSE CEO Paul Reid have all said previously that Ireland is in the “top tier” of European countries when it comes to testing relative to our population size (despite the problematic nature of per capita comparisons in relation to death tolls).
But this claim has been somewhat undermined by missed targets, long delays for results and contact tracing and a tight case definition, that is, the requirements needed for someone to be sent forward for a test, limiting demand.
Until yesterday, GPs were advised only to refer people for a test if they have a fever or chills AND a cough or shortness of breath, and if they were in a number of priority groups, including close contacts of a confirmed case, health workers and at-risk groups.
Proof of the restrictive nature of this definition was evident last night, when Chief Medical Officer Dr Tony Holohan told reporters that current capacity exceeded the number of tests carried out last week – around 40,000, or 40% of the ‘magic number’.
And even though the case definition was widened from yesterday, it is still viewed by many as restrictive: although it expanded the previous definition to include any of the above symptoms, it retains the requirement for a patient to be in a priority group.
As it stands, the current definition will have to be widened again before 100,000 people a week are even able to be put forward for a test, regardless of capacity.
Teething problems
So what has happened in the six weeks since the WHO’s warning to test and isolate Covid-19 cases quickly and efficiently?
Home testing has been arranged through the National Ambulance Service (NAS) and dozens of designated centres are now up and running, including a drive-through facility at Croke Park and in a Defence Forces ship moored on Dublin’s quays.
The system has dealt with numerous teething problems, including the closure of some of those centres.
In the first few weeks of testing, Ireland experienced some of the same problems seen in other countries with shortages in supplies of swabs (the medical equipment used to sample patients) and reagent (the chemical used to analyse a test to produce a positive or negative result).
The latter prompted between 25,000 and 30,000 tests to be outsourced to Germany earlier this month to clear the backlog.
Surge in test numbers
On top of this, Ireland has already had an insight into what happens when the demand for tests outstrips the capacity of the system to carry them out.
When Covid-19 was first detected in March, the HSE limited testing to close contacts of confirmed cases or those who’d travelled from affected areas, such as northern Italy.
But as the virus spread, testing was expanded to anyone showing one or more flu-like symptoms.
Demand for tests subsequently surged, as patients flocked to get tested at a time when most were still struggling to understand the virus and how it could impact their health.
GPs reported being unable to contact the HSE, and such was the demand that an online system to arrange test crashed on its first day in operation.
By the end of its first week, 40,000 people were waiting to be tested while there was capacity to carry out just 6,000 tests a day.
At the end of March, around 20,000 people a day were being referred for tests and the Chief Medical Officer acknowledged the net may have been cast too widely.
“If we were to test at that [rate], we would by a considerable distance become the number one country in the world for testing,” he said at the time.
“What that says for us is that a lot of the health seeking behaviour in requests for testing are people who are not appropriate for testing, and we needed to think about focusing our case definition to identify people with a higher probability of having this particular infection.”
When the case definition was changed again, huge numbers of people were cut from the list of those waiting for a test, as many who had initially been referred were no longer eligible.
The move also led to confusion among patients, with those who had been referred for a test but who had not been given an appointment removed from the waiting list.
Many were left unsure if they were to expect an appointment anyway, while those who were still eligible under the new case definition had to start the process again and re-apply to be tested through their GP.
Ramping up testing
However, after overcoming those initial problems, testing has gradually been ramped up.
Two weekends ago, the health service began testing en masse across residential facilities, with a big focus on nursing home staff and residents.
Speaking at a briefing on Sunday, CEO of the HSE, Paul Reid, said that the health service plans to increase testing from 10,000 tests per day, to 12,000 per day and eventually 15,000 tests per day by the third week in May.
He also said that a long-term strategy for testing is essential to support the healthcare system and patients within it because Covid-19 will likely be around for years to come.
“The model we have put in place, as described a few times, has been a type of war zone model,” he said.
“We put all the elements together, we’re going to maximise efficiency and we’re going to increase it’s volume.”
From Tuesday 21 April to Monday 27 April (inclusive), 41,470 tests were carried out in laboratories.
To recap for context, around 10,000 tests in total had been carried out by the middle of March (the first case having been reported on 29 February), with a further 20,000 on top of that again by the end of last month, so Ireland’s capacity has been increasing. Just not at the rate needed to hit the targets set by Harris and other health officials.
Dr Cillian de Gascun revealed last night that we’re still almost three weeks away from reaching the 100,000 target.
What’s more, there are still issues with turnaround times for tests. While those in hospitals are receiving their results between 24 to 36 hours later, those in the community are reporting having to wait up to a week, sometimes even longer.
However, de Gascun told TheJournal.ie that the health officials are importing more testing equipment for to ensure that capacity can be increased in the coming weeks.
“When we initially made the plan and ordered the equipment, we envisaged it being on the island [of Ireland] and up and running a little bit sooner,” he said.
“We’ve also secured additional capacity overseas in Germany; people will already be familiar with the assistance they’ve provided. That’s coming on stream probably in the second half of this week and early next week.”
A new contact tracing app is also expected to be up and running by the end of May to support efforts for a long-term testing and tracing model, allowing patients to be identified and isolated more efficiently.
But although officials have held up 100,000 tests per week as a target, it’s been suggested that this is still a point of contention between the HSE and the Department of Health.
Last week, the NPHET cautioned that a testing capacity of 100,000 per week may not be possible, while Health Minister Simon Harris suggested that there may not be a need for upwards of 10,000 tests to be carried out daily.
That would mean 70,000 tests a week, almost a third below the 100,000 target.
And there have also been tensions with medical professionals. Commenting on the widening of the case definition yesterday, Mary Favier of the Irish College of General Practitioners warned that more testing would increase pressure on GPs.
“If the capacity is not there then unacceptable waiting times for testing and return of test results builds up and we end up not being able to deliver the amount of testing that is required,” she said.
“In addition, contact tracing needs to be timely and appropriately organised in order to deal with the anticipated rise in new cases revealed by increased testing…
“Without this resource being widely and consistently available, we will see a further inevitable surge in infection rates.”
Without a vaccine, testing capacity must increase before any restrictions can be lifted, according to all public health logic, but it is not a silver bullet either.
Professor Sam McConkey, the head of the Department of International Health and Tropical Medicine at the Royal College of Surgeons in Ireland, is among those who have urged the government not to be too hasty about lifting restrictions.
“By really going hell for leather and doing all we can do for the next week or two and getting the numbers down so there is no more community transmission of Covid-19,” he said.
“We need to get unexplained community transmissions down almost to nothing before we relax and start doing everything that we’d like to do again.”
With issues like this, it seems unlikely that restrictions will be significantly eased by the government next week.
Although Ireland’s testing system has come a long way, it may take until the middle of next month before we can even begin to contemplate a return to normality.
With reporting from Press Association.
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