Testing For Coronavirus – Can Latin America and Africa Build Upon The Asian Model?     
Medellin, Colombia’s Parque de las Luces stands empty on bank holiday after city and regional leaders call on the population to stay indoors due to COVID-19 threat.

In normal times, Diego Zapata, undersecretary in the City of Medellin’s Mobility Department, worries about how to advance better public transit systems, cycling and pedestrian networks – to get more people moving around the city.

But recently, he and his boss Carlos Cadena began supporting the City’s Health Department in its scramble to reduce travel around the city – and scale up capacity to rapidly diagnose new COVID-19 cases so that Colombia’s second largest city can head off a wider, and more devastating outbreak of the novel coronavirus. 

The disease is just now beginning to gain a foothold in Latin America and Africa.  As of Tuesday, some 52 people in the Medellin metropolitan region and 378 Colombians nationally had been reported ill. 

Just a week ago, tests for COVID-19 could only be done in the national laboratory in Bogota, leading to considerable delays and limiting local test capacity. But on Friday, a breakthrough occurred – the Antioquia Regional Laboratory in Medellin also began conducting tests, after training staff and securing precious reagents. 

“There is an urgent need to improve regional and local testing capacity to try to contain the pandemic”, says Zapata last week, in an interview with Health Policy Watch. As a clean air and mobility advocate, he has been particularly worried that Medellin’s population, includes many older people and migrants, who have suffered a period of chronic exposure to heavy air pollution emitted by forest fires in Colombia’s northern region, could be particularly vulnerable to the impacts of the virus on respiratory health.

Diego Zapata at work in normal times promoting clean, sustainable transport for Medellin, Colombia.

Such concerns reflect the “whole of government” approach that some lesser-affected cities and regions in Africa and Latin America are now putting in place to get ahead of the virus wave, as well as the steady global uptake of a key message issued by WHO’s Director General Dr Tedros Adhanom Ghebreyesus, who told the world last week that expanded use of diagnostics is key to fighting the outbreak: 

“Test, test, test. You cannot fight a fire blindfolded. And we cannot stop this pandemic if we don’t know who is infected,” said Dr Tedros.   

That message was underlined again on Sunday by WHO’s Emergency Head Mike Ryan. He told the BBC’s Andrew Marr that the lockdown measures being widely used in Europe and elsewhere are not enough on their own to solve the crisis. Such restrictions in Asia only succeeded because they were also accompanied by rigorous testing – “once we’ve suppressed the transmission, we have to go after the virus,” he said.   

Indeed, while some countries and cities have appeared almost lethargic about testing, other countries, regions and cities are racing to find new and creative ways to activate testing and other local measures, with any available resources.  

The challenges and opportunities cut across economic and geographic fault lines – from high-income Europe, the new virus epicentre, to North America and low- and middle-income countries of Africa and Latin America. Regional and local laboratories like Medellin’s, which sprawls across a metropolitan area of nearly 4 million people, are gearing up, and new rapid tests are just coming online, offering hope that more and more cities and regions in low- and middle-income areas can accelerate testing capacity.  

Early on in the epidemic, however, Asia created some good practice examples for how diagnostics can be wielded to stem the tide of new cases – in the context of broader public health strategies. And Africa is eyeing the development of rapid COVID-19 test technologies – which have contributed so much in turning the tide on infectious diseases such as malaria and HIV/AIDs.    

Health Policy Watch (HPW) looks at the diagnostics landscape through the lens of these Asian stories of success, as well as the promising new innovations such as rapid diagnostics now on the horizon – while recognizing that there is no “one-size-fits all” approach.  

(HPW/Svet Lustig): How countries rank in COVID-19 tests/per million population. Developed from national test data collected by FIND (finddx.org) as of 24 March, 2020.

The Republic of Korea: Tested Like Mad – No Nationwide Lockdown Imposed 

Any story on diagnostics has to begin with the Republic of Korea, founder of the now legendary “drive-in” test sites, and the country outside of China with the largest COVID-19 test capacity in the world – with 6,471 people tested per million, or about 15,000 tests per day. 

Korea’s decisive measures centered on widespread testing, transparency and education have helped slow down the outbreak and minimize panic amongst civilians.

Schools and kindergartens closed, and mass events were cancelled. The southeastern cities of Cheongdo and Daegu, and parts of North Gyeongsang province as “special disaster zones”. But thanks to its aggressive testing and contact tracing early on, Korea largely avoided the kinds of massive commercial shutdowns and widespread restrictions on individual movement that are now being seen in Europe and North America.  

(HPW/Svet Lustig): COVID-19 test trends in selected low- and middle-income countries of WHO’s Western Pacific (WPRO), Eastern Mediterranean (EMRO) and Americas (AMRO) regions. Developed from national test data collected by FIND (finddx.org) as of 24 March, 2020.

 

(HPW/Svet Lustig): COVID-19 test trends in selected countries of WHO’s European Region. Developed from national test data collected by FIND (finddx.org) as of 24 March, 2020.

The integrated strategy also helped keep mortality rates down. Death due to Covid-19 in Korea have so far been three times less than the global average

“It’s much better to test and then quarantine a specific person than to do a city-wide or province-wide lockdown, which in certain ways prevents the virus from leaving the province but actually doesn’t make the province any less likely to have high infection rates,” says Dr.Eric Feigl-Ding, a senior fellow at the Federation of American Scientists in Washington, D.C., and an epidemiologist at the Harvard Chan School of Public Health.

A Network Approach to Laboratory Response

With the memories of the 2015 outbreak of Middle-East Respiratory Syndrome (MERS), which killed some 38 Koreans, fresh in mind, the country already had undertaken key reforms to allow quick approval of new diagnostics during emergencies, maintain local production capacity, and link public and private labs together in a national network. 

This allowed Korean manufacturers to design and create a COVID-19 test, as well as get a network of 96 labs across the country to work on manufacturing and using it, within 17 days, Professor Gye Cheol Kwon, the chairman of the Laboratory Medicine Foundation, told the BBC. The organized network function also helped avoid the inconsistencies in test quality, production rates and distribution, seen in other countries.

Inspectors visit a drive-in COVID-19 test site in Busan, Republic of Korea

Test Strategy Cast a Dragnet

With plenty of tests available across the country, thanks to the well-organized laboratory network, Korea focused its very first rounds of testing around the contacts of the first clusters of COVID-19 infections emerging among travelers returning from abroad as well testing all 210,000 members of the cult-like Shincheonji church in the southeastern city of Daegu as well as North Gyeongsang province, where the first virus clusters had emerged. 

Much broader criteria were soon adopted; these enabled anyone with a simple doctor’s note to get a free test. Those lacking a note could still get a test for US$130. Any subsequent  hospitalization and treatment were also offered for free – further incentivizing people to get the tests without fear of debilitating health care costs. This contrasts sharply with the approaches that are now being taken in some European countries, such as France and Switzerland, where decisions on testing remain in the hands of health care providers and only people deemed to be highly symptomatic or at high risk are allowed to be tested at all.  

A hallmark of Korea’s Covid-19 response has been their drive-thru testing centres. The procedure takes approximately 10 minutes, and is able to test 10 people per hour, which is twice as fast as diagnosis in an indoor clinic. Briefly, drivers are asked to answer a short questionnaire, their temperature is taken and they are swabbed inside their nose. This approach has been shown to be convenient and safe, especially for front-line workers and patients in waiting rooms, limiting the potential for the virus to spread. 

In densely populated city centers, where vehicles are less common, Korea also implemented mobile testing stations and staged home visits, which allowed for the identification of positive cases within hours. 

Testing Part of Integrated Strategy 

The government has also promoted social distancing, encouraging the roll-out of church services online in the devout population. The government also invested heavily in digital and social media outreach, including personalized mobile phone messages complementing 2x daily public press briefings. 

Creative uses of digital technologies also played a role. The government used private civilian phone data to anonymously track positive cases by GPS location. Applications, such as Corona100m, also used such publicly-available data to help civilians avoid high-risk areas linked to the Covid-19 outbreak in a user-friendly fashion, even as they moved about freely, in most cases. 

Via Corona100m, users received phone alerts if their proximity to any recorded case was less than 100 meters. The phone app was downloaded 1 million times within 10 days of its launch. Although the information is ‘anonymized’, concerns also arose, however, about privacy infringements.  

Instead of shutting down airports completely, Korea last week adopted additional screening and mandatory quarantine measures, for all Koreans as well as foreign nationals into the country.  This also helped mitigate Covid’s impacts on the economy. 

From its precarious ranking as the largest cluster of cases outside China in mid February, Korea this week had 5884 active cases, and was reporting only about 94 new cases a day on average, last week.

“We must maintain this trend. We have come this far thanks to the citizens who were united and cooperated well with the government. But it’s too early to be optimistic. Please be a little bit more patient and stay away from mass gatherings such as religious events. Moon Jae-in, Korea’s president, told The Guardian recently.

“South Korea showed to the world that it can allow curtailing a pandemic with limited infringements to individual freedom and disruption to the economy and the fabric of society,” Dr. Balloux wrote.

Singapore: Public Health Preparedness Clinics Take Load Off Mainstream Health Services 

Singapore light rail lines continued to operate at height of COVID-19 emergency. Source: Jade Lee.

Singapore was one of the first countries outside of China to be hit by Covid-19, and had the highest number of cases outside of China for almost two weeks in February 2020 (05/02/2020-18/02/2020). It’s successes in “flattening the curve” since have made it the country with the slowest Covid-19 growth rates in the world (doubling time of 7 days).  

“Test, test test”  was also a cornerstone of the city-state’s policy from the beginning – including broad criteria for who should get a test, free testing, and diligent tracing of contacts of confirmed cases.  

While Korea created drive-in test sites, a hallmark of Singapore’s outbreak response was the re-activation of its Pandemic Preparedness Clinics, used in the H1N1 flu era and in air pollution haze events, to administer tests and provide follow-up. 

Rebranded as “Public Health Preparedness Clinics,” the 900 PHPCs offer COVID-19 tests to the public in venues separated from mainstream health services, protecting patients and health workers alike. 

The Ministry of Health recommends any patient with respiratory symptoms, fever, cough, sore throat and runny nose seek help at PHCPs, which are mandated to not only test, but also dispense initial treatments, and conduct follow-up investigations. As an additional precaution to ensure that no potential case remained unidentified, Singapore’s health authorities also mandated private doctors to test any patient with flu or pneumonia-like symptoms. 

Ramping up Local Diagnostics Capacity .

Even before COVID-19 first hit Singapore on February 23 2020, diagnostics were also widely accessible. Within a week of Covid-19’s sequencing by Chinese scientists (12 January 2020), the Multi-Ministry Taskforce coordinating COVID-19 response had done the necessary legwork to organize local manufacture of large quantities of diagnostic tests.

As of 25 March, the widely available and free testing (with a doctor’s note) had helped identify a total of 8930 close contacts of known virus cases. All such contacts, as well as travelers arriving from elsewhere, are quarantined for 14 days. Of the contacts, 6287 have completed their quarantine and 2643 are still under quarantine. But other Singaporeans can move about freely.  An antibody blood test was also used to help investigators track down the source of the original large outbreak, which was linked to a church group, STAT News reported.  

Modest (yet effective) Social Distancing measures 

Dorcson alert levels. Source: Singapore Ministry of Health.

While Singapore has social distancing measures, the approach stands in stark contrast to the much stricter measures adopted in Europe or the ‘shelter-in place’ orders in USA hotspots. 

Schools remain open, although children’s temperatures are screened prior to entry. Singapore reduced the scale of public events to below 250 participants, which is still far less restrictive than recent measures seen in Europe. To protect the elderly, all “senior-centric activities” are suspended until the beginning of April.

While the Ministry of Health has previously said that risks to the public “from transient contact, such as in public places, is low,” last week it issued stricter advice to reduce frequency of get-togethers and socializing. 

“Social responsibility is a critical factor in slowing the transmission of the virus. We need all Singaporeans to play their part in the fight against COVID-19…This means reducing the frequency of [get-togethers], and minimising physical contact with one another. Those who are unwell, even with mild flu-like symptoms, should see a doctor and stay at home to prevent spreading illness to others.”, stated the Ministry of Health of Singapore in a press release.

Singaporeans have expressed strong support for the government’s early and aggressive testing measures. 

Full faith in the medical personnel of Singapore,” wrote one Singaporean, Joyce Chan, who went to the doctor for a simple cough and wound up getting a COVID-19 test.  

“With such dedicated medical professionals and good systems and processes in place, I have full confidence that Singapore can handle this situation well. Now, more than ever, is the time to seek treatment if you are feeling unwell (instead of potentially passing any virus on to others)….The experience gave me 100% confidence in Singapore’s preparedness to contain and deal with the current #Covid19 situation”, said Chan, who agreed to be quoted by Health Policy Watch.

SARS was a Template for Singapore Response 

The residual traumas of the SARS epidemic of 2003, as well as the H1N1 crisis of 2009, were etched into collective memories and that helped spur Sinaporeans to rapid, collective action, observes local journalist Jade Lee. 

“Singapore was hit by SARS in 2003, and that gave Singapore a template for response,” she said. “It was the lived experience that made Singapore much more cautious early on. We had the advantage of moving fast and aggressively against the virus from the beginning.”

Efficient governance also helps. 

Singapore is a good example of an all-of-government approach – Prime Minister Lee Hsien Loong’s regular videos are helping to explain the risks and reassure people”, said  Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization in a press briefing on Covid-19.

As Dale Fisher, professor at the National University of Singapore, noted in an interview with The Guardian: “We [Singapore] don’t do anything different, we just do it well.”

Gearing Up in Africa – GeneXpert and Rapid Diagnostic Tests  

A scientist at Ethiopia’s National Influenza and Arbovirus Laboratory, equipped to test for COVID-19.

Right after an international public health emergency was declared, WHO launched a massive drive to equip African health systems, deemed to be the most vulnerable,  with tools to test and treat patients.  

In early February, WHO shipped over 200,000 tests to 47 countries across the continent and trained national labs or central hospitals in 40 countries to process test results. 

Paradoxically, the virus headed north instead, over ever widening swathes of Asia, Europe, The Middle East, and North America, while Africa was largely spared. 

Now, however, as Africa begins to see its first real wave of cases, those initial tests are rapidly being used up, notes Owen Kaluwa, WHO Representative for South Africa, which received just 2,500. 

“There were 200,000 kits for the 47 countries that our offices are covering,” he said at a WHO Africa Region Office press briefing last week. “This is what they started with and what they are using now, most are requesting replenishment, as they are seeing increasing numbers of cases. 

In light of the greater infectious potential of the virus, and sheer numbers of people becoming ill elsewhere, African health authorities are hoping to see the expedited development of rapid diagnostics tests – which played such a large role in combating other diseases like HIV/AIDs and malaria.  

Speaking at the press briefing on 19 March, Matshidiso Moeti, WHO Regional Director for Africa, said that African nations want tolearn from the experiences of other countries which have seen a sharp decline in COVID-19 cases through rapidly scaling up testing, isolating cases and meticulously tracking contacts.”

Owen Kaluwa, WHO/South Africa (left); Dr. Matshidiso Moeti, WHO Africa Regional Director (center)

But she added that Africa would need more low-cost and rapid test solutions to be effective. 

“As regards the test kits and the global challenges in their availability.. we would like to encourage a very focused screening and case finding strategy where those who have symptoms and their close contacts would be tested, and that would allow us to initiate the measures around social distancing, hygiene, isolation that are so important,” Moeti said.

“We are aware that there is a challenge. But we are very keen to explore test kits and testing approaches that will be carried out in a minimally demanding way, and as broadly as possible, before or right when people start showing symptoms”, Moeti said.

According to FIND, the Geneva-based non-profit public-private diagnostics partnership, there are already nearly 100 some rapid tests, mainly antibody blood tests, already commercialized in China and the Republic of Korea, and elsewhere in Asia. 

In the USA, the first antibody blood test, developed by Mount Sinai’s Icahn School of Medicine, was now due to be piloted soon in the USA COVID-19 epicentre of New York City. The test can also identify who has been exposed to the virus and may be immune or asymptomatic. 

The US FDA has agreed that body-fluid tests can be marketed with an abridged process of agency review. 

Other such tests are also under development in Europe, North America and elsewhere. But none so far have received a WHO, European or US regulatory seal of approval to a level that would pave the way for bulk, donor-funded purchases and use in clinics and field settings, such as Africa. 

The UK-based firm, Mologic, however, hopes to be one of the first approved for the African market. It has announced plans to roll out a rapid test being developed in a collaboration with Senegal’s Institut Pasteur de Dakar as early as April.  The test is to be manufactured in Senegal by the pharma company DiaTropix, with prototypes to be ready in mid-April, according to the manager of DiaTropix, Cheikh Tidiane Diagne. 

Mologic has received £1 million to develop the test as part of the UK government’s £46 million international coronavirus (COVID-19) prevention and research funding package, and the aim is to manufacture the test for as little as £1.

While targeting Africa first, high-income countries swamped with Covid-19 cases will also benefit from the emergence of new rapid tests, said Mologic Medical Director Joe Fitchett, in the company’s press release.    

“The COVID-19 outbreak is at a critical juncture, and to bring it to an end, we need next- generation diagnostics for use at the point-of-need – at home or in the community, in limited and well-resourced settings,” he said. 

(HPW/Svet Lustig): COVID-19 test trends in selected high-income countries of WHO’s Americas (AMRO), African and South East Asia (EMRO) regions. Developed from national test data collected by FIND (finddx.org) as of 24 March, 2020.

Meanwhile, the worldwide network of some 10,000 GeneXpert® diagnostics – traditionally used to test for TB – may provide Africa and other low- and middle-income countries with another important interim solution.  A new COVID-19 test for the GeneXpert platform was just approved last week by the US FDA, and medicines access advocates are now calling for the test price to be reduce from $US 20 to $US 5 for the 145 low- and middle-income countries that procure GeneXpert tests at concessionary prices, under arrangements with donors and international agencies such as WHO and the The Global Fund to Fight AIDS, Tuberculosis and Malaria. 

“The GeneXpert® platform could fill a crucial need, especially in low- and middle-income countries,” Paula Fujwara, Scientific Director of the International Union Against Tuberculosis and Lung Disease (The Union), told Health Policy Watch on Monday. “The need for testing is immense as we still don’t know the true number of people who are infected in the world,” she added, and adapting the GeneXpert platforms in low- and  middle-income countries to COVID-19 testing could be “easily and rapidly done,” since the technology is already well-known.

Colombia: Ramping up Tests and Social Distancing Measures 

Medellin, Colombia’s second largest city

As of 18 March, fewer than 3,000 tests had been performed in Medellin; six days later the national number had grown to 7240 tests – with 378 cases confirmed. The largest case cluster was in the capital city of Bogota, while 52 cases have now been reported in Medellin, Colombia’s second largest city. 

In a comment to Health Policy Watch, Antioquia’s Secretary of Health, Luis Gonzalo Morales said, “We have test capacity at our regional laboratory in Antioquia to undertake the tests. Early this week we have begun the process. We have sufficient reagents to undertake the quantity of tests necessary based on the criteria that has been set by the Ministry of Health.” 

Zapata also credits the Antioquia regional governor, Anibal Gaviria, and Medellin Mayor Daniel Quintero, with strengthening policies on social distancing, which left streets in the city largely deserted over the recent bank holiday – as well as clearing the skies of persistent air pollution. Schools have been closed since mid-March, and public gatherings have been limited. 

Still, Medellin remains vulnerable to the COVID-19 pandemic given its high population density, as well as the scarcity of hospital beds, says Zapata. For instance, it has only 850 beds equipped with respirators for the city of 2.4 million people. Furthermore, 11.4% of Medellin’s population is above the age of 65, amounting to at least 250 000 elderly at risk, Zapata stresses. 

Nationwide, Colombia has only 1.7 regular hospital beds per 1000 people, according to official Health Ministry data, as compared to Cuba (5.1 beds), Uruguay (2.7) or Panama (2.3).

Venezuelan migrants flock to city hall, creating COVID-19 transmission risks, after fake news report of emergency financial handout circulate on social media.

Fake News Can Lead To More Infections 

More than a quarter of Colombia’s population is living below the poverty line. And in Medellin, especially, large migrant population of Venezuelan migrants remain vulnerable, including to misinformation. 

A recent fake WhatsApp message sent hordes of Medellin migrants running to the Municipality headquarters thinking that they would get a handout of money due to the COVID emergency.  Also, Medellin continues to face chronically high levels of air pollution due to forest fires burning in the north, notes Zapata.

Still, Zapata is hopeful that the recent pre-emptive measures, along with stepped up testing, are now having an impact. There are fewer people on the streets and in the buses.  And more than 100 technology volunteers working with a local non-profit initiative, #InnspiraMED, which has created three prototype mechanical ventilators from open-source technologies. The initiative aims to bring the prototypes to scale locally, as well as generating models that can be copied elsewhere around the world. 

Meanwhile, Zapata is now working from home along with his boss, Medellin Mobility Secretary, Carlos Cadena, directing  essential daily operations of traffic workers and contractors. Zapata is happy that at least air pollution had been reduced somewhat, as a result of the lighter traffic in the city. 

Cadena recently tested positive himself for COVID-19, trying to plan ways to reduce traffic and rationalize public transport flows, in ways that also reduce commuters’ infection risks. As a close contact, Zapata was tested — and is still awaiting results. 

Cadena, who shot an upbeat video message from isolation at home after being diagnosed, with a picture of a bicycle in the background, continues to work from home, while recovering. 

“He is ill, but he has remained on the front lines,” says Zapata. 

Carlos Cadena, Mobility Secretary, Medellin: will keep working from home, while recovering from COVID-19.

Image Credits: Diego Zapata , Busan Metropolitan City, Jade Lee, Singapore Ministry of Health, WHO AFRO/Otto B., HPW, Carlos Cadena.

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