The place of testing in the management of COVID-19

Setting the context

 How can testing help reduce the spread of COVID-19?

An effective testing approach provides a crucial window into the pandemic and enables better understanding of how the virus spreads. Testing allows countries to identify infected individuals and guides the medical treatment that they receive. It enables the safe isolation of all people infected, and the subsequent tracing and quarantining of their contacts. It can also help allocate medical resources, equipment, funding and staff more efficiently.

In addition, testing for COVID-19 also deepens knowledge of the pandemic and the level of risk it poses within different populations. This is crucial to equip countries with knowledge to assess the interventions that need to be implemented, including comparatively costly interventions such as social distancing and the shutdown of entire regions and industries.

Testing coverage and the number of tests per confirmed case help countries understand the severity and spread of the coronavirus better. The number of tests per confirmed case is known to be the most helpful indicator in this regard, because it accounts for the fact that smaller outbreaks require less testing. Testing coverage depends on the strategy a country employs – mass testing or targeted testing. Which approach a country chooses is highly dependent on available capacity and resources.

Mass testing is generally offered to every individual in the country, regardless of level of risk, socio-economic background, immigration status or geographical location. Hence, mass testing is more widespread, and consequently, more expensive to the government. Targeted testing, by contrast, focuses on specific groups of individuals based on a set of criteria. For example, it might be offered to only those with symptoms, to overseas travellers entering the country or to individuals who have had contact with confirmed COVID-19 cases.

Several top recovering countries, including New Zealand, Iceland and Germany, are actively conducting mass testing as they move to more advanced stages of recovery. Other recovering countries, such as Singapore, Canada and Tunisia, are still pursuing targeted testing.

When COVID-19 diagnostic tests are available, people who test positive and have symptoms can receive earlier care. Contacts can be traced, and self-isolation or quarantine can commence sooner to help stop the spread of the virus.

  • However, no COVID-19 test is 100 per cent accurate. It is possible to test negative yet be infected (a false-negative result). When accurate antibody tests become widely available, results will indicate how many people have had COVID-19 and recovered, including those who never had symptoms. This will make it possible to determine who is likely to have immunity.

Different types of tests for COVID-19

There are many different technologies for COVID-19 testing, some currently available and some still in development. Broadly, these different tests can be divided into 3 types:


Figure 7: Types of testing for COVID-19[8]

Analysis on COVID-19 testing statistics for select countries

Analysis on test data was conducted on a selection of countries which included high-income, upper middle-income, lower middle-income and low-income countries, as well as those with both high and low recovery rates.

A key question to ask is: How many tests should a country conduct to find one COVID-19 case? There is a significant difference across countries on testing coverage for each confirmed case.

  • Some countries, such as New Zealand, Iceland, Australia and Taiwan do hundreds of tests for each case that they find.
  • Others, such as Indonesia, Nigeria, and Peru only do a handful of tests – ten or fewer – for every confirmed case.

Number of COVID-19 tests per confirmed case for select countries under different income groups



Figure 8: COVID-19 testing statistics for select countries
Source: Official sources collated by Our World in Data [1]

Note: Tests per confirmed case is defined as the number of tests conducted over the number of positive COVID-19 diagnoses. This measurement provides a good assessment of how widely countries are testing by comparing the number of tests performed to find a COVID-19 case.

Based on testing data as of 17 May 2020, New Zealand tops the list for number of COVID-19 tests per confirmed case, followed by Tunisia, Iceland, Australia, Thailand and Taiwan.

Number of COVID-19 tests per confirmed case for top 20 GCI countries and Sweden

Figure 9: COVID-19 testing statistics for top 20 GCI countries and Sweden
Source: Official sources collated by Our World in Data [2]

Key finding from the analysis

Key finding 1: Strategic testing is key to understanding the spread of the infection.

  • Testing strategies that focus on high-risk and susceptible individuals within the population in order to identify infection clusters, high-risk communities, and targeted areas for testing are important in enabling the government to take immediate action to break the transmission chain.
  • Given the importance of rapid response at the beginning of the outbreak, the timing of testing is crucial; a high rate of testing will do more to slow the outbreak if conducted early on when there are fewer infections. Until an effective vaccine or treatment is available, strategic testing continues to be critical in managing public health recovery.

Countries can benefit by setting themselves up to commence testing activities early in the outbreak of a communicable disease. A rapid response through testing leads to quick identification of cases and prompt treatment for identified cases. Early testing also helps identify individuals who have been in contact with those infected; treatment or quarantine can then follow.

Since the beginning of the coronavirus pandemic, the WHO has emphasised the importance of testing, which needs to be complemented with an effective track and trace approach, in the fight to contain and reduce the impact of COVID-19.

In addition to early testing interventions, there are benefits in ensuring the proportion of the population tested is significant. Mass testing is a fundamental practice of typical pandemic response. Historically, it has been widely adopted as a mitigation model. Mass testing helps limit the spread of the virus and paves the way for a range of measures to flatten the curve of cases and deaths.

Countries that do very limited tests per confirmed case may not find and identify all cases. The WHO has suggested around 10 – 30 tests per confirmed case as a general benchmark of adequate testing.[9]

In the early stages of a pandemic, when clusters are typically few and far between, three interventions are crucial: identifying infected individuals; identifying their household cluster and tracing individuals they have been in contact with; and quarantining them until they no longer carry the risk of transmitting the infection.

Even at a later stage of the outbreak, building the capacity for mass testing and isolation can continue to separate infective and non-infective individuals and communities – allowing health and economic recovery to take place simultaneously. Individuals that test negative and have not been exposed, for instance, can continue to engage in economic activities as opposed to being in total lockdown.[10] Although building capacity for mass testing is expensive, the longer-term economic benefits can be worth it.

Effective mass testing also helps protect health workers and enables officials to measure the progression of a pandemic. It can provide evidence about regional variation and how the virus affects people of different ages and genders. Virologists can use information about cases to monitor the nature of the virus and any mutations. This valuable testing data can show social and behavioural scientists whether other measures such as physical distancing are working.

Testing processes also need to go hand in hand with aggressive contact tracing via effective track and trace mechanisms in order to keep the infection rate to a minimum. Individuals who may have been in contact with an infected patient are likely to have greater risk of COVID-19 infection. Hence, testing and isolating patients with COVID-19 symptoms (together with their identified contacts) helps reduce the risk of the virus spreading.

In cities with dense living conditions, which make social distancing measures harder to practice within the community, it makes sense for the testing strategy to be more aggressive and rigorous.

Effective Practice Case Study: New Zealand

Testing before confirming its first COVID-19 case enabled New Zealand to win in the fight against the pandemic

New Zealand’s Ministry of Health reported that they started testing for the novel coronavirus on 22 January 2020, four weeks before the country’s first confirmed case. As of 17 May 2020, New Zealand, which has a population of only five million, had tested 230,718 people with a positive rate of 0.7 per cent. As a result of this early intervention, New Zealand had the highest number of tests per confirmed case in the world at 5,950. Testing has been focused on people with symptoms, as well as on tracing both close and casual contacts.

Figure 10: Active cases vs number of tests conducted – New Zealand

Highlights:

  • In addition to being quick to enact lockdown measures, New Zealand worked hard to ramp up testing. At its peak, the country had the capacity to process up to 8,000 tests per day, resulting in New Zealand having one of highest testing rates per capita in the world at 1.06 tests per thousand people.[11]
  • Based on WHO’s general benchmark of adequate testing (between 10 – 30 tests per confirmed case), New Zealand has performed remarkably well. As of 17 May 2020, it has conducted over 7,300 tests per confirmed case, which suggests that there is no undetected widespread community transmission in New Zealand.[12]
  • New Zealand introduced more widespread testing as their response evolved. The Ministry of Health arranged testing for specific communities who are at higher risk of contracting the virus, such as those in aged residential care facilities and healthcare workers. At the time of writing, testing samples from sewerages was also being considered to monitor control and elimination.
  • As New Zealand moves towards zero community transmission and eliminating the virus, caution needs to be noted over the drop in testing rates; as fewer people present with symptoms and as they resume normal activities (i.e. work and school), reduced community awareness of the need for testing may lead to lower rates of uptake.

Effective Practice Case Study: Malaysia
Early targeted testing led to the discovery of clusters in Malaysia

During Malaysia’s early coronavirus infection wave in January and February 2020, Malaysia’s Ministry of Health conducted random testing of people with flu symptoms and adopted extensive contact tracing to identify people who needed to be screened for COVID-19. This early strategy enabled the Ministry to identify clusters effectively, which were then prioritised for targeted mass testing. This provided the government a clear picture of community transmission and overall virus spread, while exerting effort to expand its nationwide testing capacity.

Since the end of March 2020, identified COVID-19 hotspots have been placed under strict quarantine measures via the enhanced movement control order (EMCO), and mobile testing deployed to test all residents regardless of symptoms. It has also enabled and encouraged undocumented immigrants to be tested and obtain healthcare services without recrimination.

As of May 2020, Malaysia had tested over 500,000 individuals for COVID-19, which translates to 16.65 tests per thousand people, with a positivity rate of 1.45 per cent.[13]

Highlights

  • Malaysia’s Ministry of Health has been using a targeted approach in deploying its COVID-19 testing due to the significant cost that would have been required to test everyone in the country.
  • Through early detection and screening of high-risk target groups, Malaysia has been able to gradually reduce the number of active COVID-19 cases, as shown in Figure 11.
  • The targeted approach to active case detection conducted by the Ministry has identified eight key groups effectively so far, namely:
    • Participants of a religious assembly and their close contacts
    • Students and staff of madrasah and tahfiz[14] schools linked to the religious assembly
    • Malaysians returning from overseas and placed in quarantine centres
    • Healthcare staff
    • Residents within areas placed under the EMCO
    • Kuala Lumpur wholesale market and other linked wet markets
    • Foreign workers on construction sites within red zones[15]
    • Nursing homes for the elderly

  • By prioritising specific target groups, Malaysia has also been able to expand its overall testing capacity via the optimisation of existing government-run testing facilities, establishing new testing facilities, and authorization of private laboratories to run diagnostic tests for paying and insured individuals.
  • As of 1 June 2020, Malaysia’s Ministry of Health’s proactive effort in testing has successfully expanded daily testing capacity to 29,789 PCR tests. This capacity would be further supported by the employment of the Rapid Test Kit Antigen (RTK Antigen), which would be prioritised for cases that require fast turnaround time, such as for the transiting travellers at the airports.


Detection of largest COVID-19 cluster in Malaysia
Malaysia’s targeted screening approach in high-risk groups managed to identify its largest COVID-19 cluster on 11 March 2020, which was linked to a mass religious gathering in Sri Petaling mosque.
The four-day gathering had approximately 16,000 attendees, including about 1,500 from outside Malaysia. Through detection from rigorous contact tracing and testing, the country saw massive spikes in local cases, and an exportation of cases to its neighbouring countries.
This cluster accounted for 3,369 out of 7,629 confirmed cases in Malaysia, or about 44 per cent, as of 28 May 2020.
Ministry of Health officials consider the targeted approach screening during the nationwide Movement Control Order (MCO) as a critical success factor in detecting and managing other subsequent clusters
Photos courtesy of New Straits Times and Free Malaysia Today
Figure 11: Active cases vs number of tests conducted – Malaysia

Case Study: IndonesiaInsufficient testing is a contributing factor to Indonesia’s upward trend in active cases, which indicates there is an undetected chain of infection in the community

Government data as of 17 May 2020 indicates that Indonesia had conducted tests on 140,479 people, a rate of about 520 tests per one million people. This is in stark contrast with its neighbours; as we’ve seen, Malaysia has conducted more than 6,500 tests per one million people, while Singapore has conducted more than 24,000 tests per one million people. With a population of 270 million, Indonesia has one of the lowest testing rates in the world.

Highlights

  • The Indonesian government is currently offering free testing at hospitals for people who have been in contact with positive cases or who have visited high-risk areas and present with COVID-19 symptoms. Individuals seeking treatment based on symptoms but without contact history are not eligible for free testing.
  • Amid the urgent need for mass testing to contain the spread of COVID-19 in Indonesia, poor people in the fourth-most-populous country in the world have had challenges accessing COVID-19 tests.
  • Rapid testing is available at private hospitals in Indonesia but is costly, ranging from USD 50 to USD 1,000 per test. Tests at private hospitals are unaffordable for millions of low-income Indonesians, leading to low rates of uptake.
  • Unequal access to testing has led to late diagnosis and preventable deaths due to undetected COVID-19 among the poor.
  • As of 17 May 2020, 17,514 people in Indonesia are reported to have been infected, with 1,148 reported deaths.  
  • Figure 12, suggesting that the chain of infection is continuing in the community.

Despite President Joko Widodo asking for a 50 per cent increase in test rates (to 30,000 per day) in July, the number of active cases has continued an upward trend as shown in


Figure 12: Active cases vs number of tests conducted – Indonesia

Key finding 2: Expansion of testing capacity can be achieved more expeditiously via active partnerships with private laboratories and healthcare providers.

  • Unleashing the untapped potential of existing testing capacity at private laboratories, such as local healthcare companies or universities, allows for quicker expansion of testing volume than relying solely on government-owned facilities and services.
  • Any limitation in terms of testing equipment, qualified manpower, testing consumables and overall funding can be addressed more efficiently when there is close collaboration between government agencies and the private sector.

With most countries’ public health sectors being pushed to capacity in testing and treating COVID-19 cases, an effective method to expand testing capacity is to partner with private sector enterprises. A number of countries have increased daily testing capacity successfully via private laboratories. These countries include Iceland, Malaysia, Australia, Singapore and Denmark.

In Singapore, the biomedical research and laboratory community was mobilised to help ramp up its testing ability. The National Diagnostics Development Hub, established by the Singapore government, integrates researchers, technology transfer offices and industry. It successfully created a test kit for clinical service in February 2020. The test kit includes a pre-packed mix of reagents to test patient samples, which are then deposited into a machine that analyses the results. The procedure helps hospitals and laboratories save time by conducting their own tests. This allows for rapid scaling of testing across Singapore.

In Denmark, a public-private cooperation significantly increased COVID-19 testing capacity. As a result of this significant partnership, within one month the Danish healthcare system managed to almost double its COVID-19 testing capacity from approximately 6,000 COVID-19 tests per day to 11,000 tests per day. As an immediate response to the COVID-19 pandemic a close collaboration between Novo Nordisk, Pentabase and Rigshospitalet was established which led to the rapid development of a new technology that increased testing capacity significantly via faster sample analyses.

Effective Practice Case Study: Iceland

Public-private partnerships increased Iceland’s testing capacity by over 130 per cent in less than a week

Iceland has undertaken comprehensive testing for COVID-19; at 17 May 2020, 15 per cent of Iceland’s inhabitants had been tested, a higher percentage than in any other country in the world.[16] This is attributed to the testing effort by Iceland Health Authorities and a private company, deCODE Genetics. deCODE Genetics offers free screening for general, non-quarantined members of the public, while more symptomatic individuals are screened at hospital testing facilities.[17]

Highlights

  • As of 17 May 2020, Iceland has tested 56,834 people, or more than 15 per cent of its 365,000-member population. It has already established a healthcare system that offers publicly funded, universal healthcare and provides a strong base for mass testing to the public.
  • However, Iceland’s testing rate of over 166 tests per 1,000 people is also largely due to a public-private partnership, which involves a pharmaceutical company (deCODE Genetics) conducting tests on people both with and without COVID-19 symptoms.
  • The initiative by deCODE Genetics to conduct large scale testing was intended to gather insight into the actual prevalence of the virus in the community, as most countries are testing symptomatic individuals exclusively.
  • Iceland has also placed significant emphasis in conducting extensive contact tracing, leveraging available resources such as nurses and police officers to identify and notify people who had come into contact with others diagnosed with COVID-19. As a result, 57 per cent of all diagnosed cases were among the group already in quarantine.[18]
  • While Iceland has now reopened to tourists, its targeted border testing has helped identify positive cases early (at least 12 out of 30,000 cases tested positive at the border) and isolate cases that could contribute to a rise in cases across the country.[19]

Figure 13: Active cases vs number of tests conducted – Iceland

Key finding 3: Implementation of innovative temporary solutions, e.g. mobile, drive-through and makeshift facilities, significantly increases testing capacity to drive large-scale testing.

  • Mobile and drive-through testing facilities are effective in limiting exposure of medical staff and other patients against transmission risk.
  • These innovative mobile testing facilities allow for sampling to be conducted on a larger group of individuals.
  • This approach also frees up hospitals and healthcare facilities for more serious cases and other healthcare needs.

Many governments around the world have reported limitations in testing capacity. These have hampered efforts to ramp up testing activities. The challenges include the inaccessibility of healthcare facilities due to distance, limited capacity in existing facilities to manage large groups  and still comply with social distancing measures, and the difficulty that high-risk, low-mobility groups face in accessing test locations. By establishing mobile and makeshift testing facilities and teams, authorities are able to make testing more easily accessible for the targeted population.

Effective Practice Case Study: Denmark

Mobile testing facilities increased testing capacity by over 100 per cent, to approximately 20,000 people per day

The Danish Ministry of Health is implementing mass COVID-19 testing for all adults in Denmark, effective from 25May 2020. The initiative is part of Denmark’s national testing strategy to prevent a second wave of the coronavirus.[20]

Highlights

  • The tests are primarily for asymptomatic adults and are conducted in white tents that TestCenter Denmark has already set up in 16 cities across the country.
  • The national testing strategy for Denmark aims to increase testing significantly within the population to break the chain of infection completely. Denmark’s total testing capacity increased by over 100 per cent in April and May 2020, with COVID-19 tests offered in hospitals, tents and at mobile testing sites. It can now conduct approximately 20,000 tests per day.
  • Until April 2020, Denmark had been testing only those with severe symptoms or related to at-risk people, due to a lack of equipment.
Figure 14: Active cases vs number of tests conducted – Denmark
  • Denmark has set up large white tents in Copenhagen and other regions to help expand its capacity for comprehensive testing.  They have also ramped up testing at international airports since reopening borders, with rapid tests and the ability for Danish residents to check their results online.
Figure 15: White tent facilities in Denmark for COVID-19 testing
Photos courtesy of The Local (Denmark News)

Effective Practice Case Study: South Korea                                                                                            
Early implementation of drive-through facilities enabled South Korea to achieve a high percentage of tests per population

Mass testing has been credited as a critical success factor for South Korea’s containment of the spread of the virus, with the number of active cases declining and consistently suppressed, as shown in Figure 17. As of 17 May 2020, the country has administered 14.24 tests per one thousand people.[21]

Highlights

  • South Korea was one of the first countries to implement drive-through testing facilities, which officials say was inspired by the drive-through counter of fast food restaurants.
  • The facilities allow individuals to drive into makeshift stations set up in parking lots, where nurses in protective plastic suits, masks and face shields register the drivers, record their temperatures, and use swabs to retrieve samples from their nasal passages and throats.
  • With the drive-through concept, passengers and drivers go through the entire testing process in a matter of minutes without getting out of their vehicles.
  • This limits the exposure of frontline workers to the virus at the test site, and ensures patients do not contaminate public health facilities. Generally, it is safer and faster to test for the virus at  drive-through sites than in a hospital or health clinic as there is less face-to-face contact.
  • Test results are communicated to the respective individual via short message service (SMS) within three days.[22]
Figure 16: Drive-through screening facility in South Korea
Photos courtesy of abcNEWS (Getty Images) and South China Morning Post (AFP)

Figure 17: Active cases vs number of tests conducted – South Korea

Mobile/makeshift Testing Facilities in Other Countries

Figure 18: COVID-19 drive-through mobile test centres in Nigeria
Photos courtesy of CNN
Figure 19: Makeshift COVID-19 testing facility in Hanoi, Vietnam
Photos courtesy of VOA News and People’s World


Effective Practice Case Study: New York City

Creative redeployment of resources can improve testing and tracing capacity

Despite relatively low levels of testing nationally in the USA,[23] New York City is on track to achieve 50,000 tests per day by 1 August by opening 12 new testing sites,[24] launching mobile testing trucks and recruiting over 2,500 contact tracers in early June. As of 20 July the state was carrying out 324 daily tests per 100,000 residents. Capacity for additional testing continues to increase for at-risk individuals, whether in hard-hit communities or those working with non-profits in vulnerable areas. Mayor Bill de Blasio hopes to test all those with symptoms, and high-risk individuals in adult-care facilities, nursing homes and shelters to improve their ability to track and trace and improve the overall health recovery.[25]

Test and trace strategies at city and state levels have also improved these governments’ ability to target high-risk populations. In New York City, a phased plan was developed to provide additional support to senior citizens and nursing home residents that included an initial two-week ‘blitz’ to provide 3,000 tests each day to nursing home residents and employees.[26]

Key finding 4: A self-assessment tool that is accessible to the public helps with mass testing prioritisation and triage.

  • A self-assessment tool is a cost-effective solution for the first phase triage in priority testing.
  • A self-assessment tool is particularly beneficial for countries with significant limitations on funding for mass testing, healthcare system and manpower capacity, and test kit supply shortages.
  • All top 20 GCI countries have implemented self-assessment tools that are available online, either provided by the government or private companies. However, there are exceptions for Cambodia, Uganda and Ethiopia where self-assessment tools could not be found online that are specific to those countries.

A self-assessment tool is provided virtually either via the internet, through mobile devices, or is based on a simple flow diagram (example shown in Figure 20) to help the public assess symptoms and determine the risk of infection and level of priority for COVID-19 testing. The tool generally offers guidance on when to seek medical care and what to do should symptoms persist.

Key benefits of implementing self-assessment tool:

  • Easily accessible to the wider population

A self-assessment tool made available virtually, either online or via mobile technology, is a fast and efficient way to reach a large number of people, especially within a population that has a vast geographical reach with a variety of languages and dialects.

  • Cost effective

A self-assessment tool is beneficial for countries with significant limitations on funding for mass testing, healthcare system and manpower capacity, and test kit supply shortages. It is a cost-effective solution for first phase triage in priority testing.

Self-assessment tools work best when there are supporting processes that ensure effective application:

  • Established protocols for all levels of assessment outcomes

The steps to take upon assessment completion can be set out in standard protocols. For example, in cases where a user is assessed as high-risk due to exposure to a confirmed patient, the established next steps should cover further testing, quarantine, treatment and contact tracing.

  • Preparedness of the healthcare infrastructure

It is important to ensure that the infrastructure is ready to support the required processes upon completion of assessment, such as testing and quarantine/isolation.

  • Accurate and up-to-date information

As understanding about the virus advances, there may be changes to the assessment parameters; real-time updates will be critical to keep advice and guidance current.

Figure 20: Example of flow diagram for self-assessment of COVID-19 risk by government of Australia

Effective Practice Case Studies in African countries

A number of countries in Africa have applied self-assessment tools

  • Nigeria: A local private company called Wellvis created a COVID-19 Triage Tool, a free online tool accessible to all to help users self-assess their coronavirus risk based on symptoms and exposure history. Depending on their answers, users are offered remote medical advice or directed to a nearby healthcare facility. The online tool has helped reduce the number of unnecessary and trivial calls to designated disease control hotlines.
Figure 21: Interactive self-assessment chatbot implemented in South Africa Photos courtesy of Bloomberg
  • South Africa: The South African government has focused its attention to utilising a WhatsApp chat service to run an interactive chatbot which can answer common queries about COVID-19 myths, symptoms and treatment. The chat service is also available for free on Unstructured Supplementary Service Data (USSD) for people without access to airtime or internet. It has now reached over 6.2 million users in five different languages since it was launched.

Effective Practice Case Study: Rwanda

Rwanda has repurposed HIV testing labs to increase testing for COVID-19

Rwanda provides nearly universal healthcare to its 13 million citizens. After the first positive case of COVID-19 was recorded on 8 March, the government immediately formed and implemented a nationwide response. The country’s timely reaction has been aided by its previous success in preventing Ebola from crossing its borders in 2019.[27]

Highlights

  • Rwanda’s mass testing approach is intentionally designed to fulfil the conditions set by the WHO for countries before lifting the COVID-19 lockdown. Since the beginning of April 2020, the Ministry of Health has carried out over 15,000 COVID-19 tests, which is 175.1 tests for every confirmed case – one of the highest rates in the world.[28] By 16 July over 194,000 tests had been carried out nationwide.[29]
  • Rwanda is increasing its coronavirus testing capacity and capability rapidly through periodic community testing, and sampling in hospitals and clinics across the country. In Kigali, the capital, a random street testing scheme has been introduced as well as a drive-in centre at the national stadium.
  • Individuals targeted in this random mass testing exercise are patients who present with influenza-like illnesses and severe acute respiratory infections. The number of those tested is increasing every day. Rwanda is now expanding the target group with those who have been in contact with confirmed cases.
  • Despite the proactive and robust government response, the government’s capacity to test for COVID-19 is still dependent on the limited capacity of the National Reference Laboratory based in Kigali.[30]
  • The government is also utilising laboratories that normally test for HIV to test for COVID-19, which allows for higher daily testing capacity.[31]
Figure 22: Active cases vs number of tests conducted – Rwanda

30-day Time Series Matrix of Severity Index vs Recovery Index for Good Practice Countries

Figure 23: 2X2 matrix of Severity Index vs Recovery Index for good practice countries

Based on the 30-day time series comparison of countries, the top 20 countries that conduct higher testing, such as New Zealand, South Korea, Thailand and Malaysia, are progressing well in terms of increase in recovery index and reduction in severity index.

Recommendations: Interventions for countries to consider        

Recommendation 1: Implement large-scale testing as soon as possible, with priority target groups identified and isolation/quarantine protocols established and enforced.

  • Large-scale testing conducted early in the outbreak, coupled with centralised quarantine facilities, have been identified as the primary drivers for flattening the curve in South Korea, Canada and Singapore. Essentially, countries with financial and operational capacity to conduct large-scale testing can consider implementing mass testing early.
  • Dedicating a budget for and enhancing capacity for large-scale testing at any point since the start of an outbreak can help manage the trade-off between health and economic recovery.
  • For countries that have limited resources, targeted testing is advisable to contain the spread, especially when supplemented with robust track and trace processes, and enforcement of isolation/quarantine protocols to break the infection chain.
  • Countries may want to prioritise access to testing to identify target groups. This is especially crucial for countries with limited visibility and understanding of how the virus is spreading within their boundaries.
  • Countries with funding and healthcare capacity limitations may want to establish the criteria for priority testing for vulnerable groups. Examples of vulnerable groups include people with travel history to high-risk areas, susceptible individuals (the elderly and those with pre-existing conditions), front-line workforce and residents in dense living quarters.

Recommendation 2: Encourage community participation in mass testing.

  • The effectiveness of mass testing in Singapore, South Korea and Australia has been underpinned by their resilient health systems and advanced surveillance technology. That may not be the case for many low- and middle-income countries. However, Rwanda has been conducting large-scale testing effectively by making use of existing laboratories that conduct HIV testing.
  • On top of good infrastructure, the government’s ability to persuade or compel people to test via clear communication, SOPs and processes is important.
  • To be effective in reducing transmission from asymptomatic cases, testing should ultimately reach a large proportion of the population and especially those living in high-risk circumstances. All top 20 countries are conducting tests at a rate greater than WHO’s general guideline of 10 to 30 tests for every confirmed case. Countries that conduct very few tests per confirmed case are unlikely to be testing widely enough to find all cases.
  • Governments should reach out to vulnerable, marginalised and economically disadvantaged populations so they can make an informed decision about participating in mass testing. The virus does not discriminate between people on the basis of their socioeconomic status; therefore, testing should be equally accessible across the population.

Recommendation 3: Capitalise on public-private partnerships to optimise testing capacity and capability.

  • Collaboration between private and public institutions can help with prohibitive overheads when it comes to growing testing capabilities. Private and non-government organisations can provide equipment, expertise, skilled manpower and funding support. Larger scale collaboration between organisations would enable larger scale testing.
  • This can be especially important in countries with constrained public healthcare systems.

[8] Source: How Reliable Are COVID-19 Tests? Depends Which One You Mean, 1 May 2020, npr

[9] Dr. Michael Ryan, WHO Media Briefing (30 March 2020)

[10] Paul Romer’s Case for Nation-wide Coronavirus Testing, The New Yorker, May 3, 2020

[11] New Zealand Ministry of Health

[12] How New Zealand eliminated Covid-19 after weeks of lockdown, CNN, 28 April 2020

[13] Ministry of Health Malaysia

[14] Madrasah and tahfiz schools are terms for religious-based schools for Islamic education in Malaysia

[15] Ministry of Health Malaysia defines three categories of Covid-19 zones: Red zones are defined as districts with at least 41 active Covid-19 cases, yellow zones with 1-40 cases, while green zones with zero active case.

[16] How Iceland Beat the Coronavirus, The New Yorker, 1 June 2020

[17] Iceland’s Aggressive COVID-19 Testing Helped Curb Outbreak, Genetic Engineering & Biotechnology News, 16 April 2020

[18] Iceland’s Aggressive COVID-19 Testing Helped Curb Outbreak, Genetic Engineering & Biotechnology News, 16 April 2020

[19] DeCODE extends participation in COVID-19 border testing as tourist numbers strain capacity, Iceland Review, 13 July 2020

[20] Denmark increases testing, contact tracing to prevent second coronavirus wave, The Straits Times, 12 May 2020

[21] Our World in Data: Total COVID-19 tests per 1,000 people, 17 May 2020

[22] South Korea Pioneers Coronavirus Drive-Through Testing Station, CNN, 3 March 2020

[23] Only 35% of the tests needed to mitigate the spread of the virus are being carried out in the US: NYT, 20 July 2020

[24] Coronavirus pandemic in the US, CNN, 26 May 2020

[25] Coronavirus NYC Updates for May 2020, Eyewitness News, 9 June 2020

[26] Coronavirus News: Mayor de Blasio unveils 4-part plan to protect NYC nursing home residents, Eyewitness News, 21 May 2020

[27] Rwanda’s Successes and Challenges in Response to COVID-19, Atlantic Council, 24 March 2020

[28] Mass COVID-19 Tests Begin as Rwanda Readies for End of Lockdown, The EastAfrican, 25 April 2020

[29] Rwanda COVID-19: Places of worship reopen amid targeted lockdowns, Africa News, 16 July 2020

[30] Rwanda’s Successes and Challenges in Response to COVID-19, Atlantic Council, 24 March 2020

[31] Rwanda to Start Using HIV Testing Laboratories to Test COVID-19 Samples, RwandaTV, 6 May 2020

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