We survived COVID-19. Now what?
What do we need to know to restart: Exit strategies & Testing
Updated: Apr 23, 2020
After more than a month of “social distancing” and lockdowns in Europe, we either start to see the first glimpses of hope or realise that we have to somehow restart life. By now, we have all realised that nothing will be the same for the foreseeable future. We get that. So, as we struggle to understand what struck us and what is happening in a time so condensed than never before, we also try to find some rationale for the next day. Some of us are almost midway in their armchair degrees in epidemiology, statistics and public health.
How hard will the economy be hit? How difficult will the recovery be, how long will it last? What will this mean for us, for our families, for our jobs, for our industries? And countless other questions.
From what I read, and believe me I have read extensively the last weeks, one thing is clear and apparent. NOBODY knows for sure. Yes, we can probably extract some understanding from past pandemics or previous financial crises, but let’s be honest, the world was a totally different place 100 years ago. Moreover, a great number of the analysts that try to explain what will happen the next day do it on very loose assumptions.
So here is what we DO know, and what we should follow.
Exit Strategies: Easing Restrictions
So far, countries in Europe layout their own national strategy depending on their needs and priorities. On its latest statement (Transition to a ‘new normal’, WHO, Apr 16) WHO outlines 6 criteria in order to ease restrictions:
- Evidence shows COVID-19 transmission is controlled. Either through lockdowns or social distancing we have less and less new cases and less people in hospitals.
- The public health system is able to identify, isolate, test, trace contacts and quarantine them.
- Outbreak risks are minimized in high-vulnerability settings (elderly homes, mental health facilities, crowded places, in case of some countries migrant camps).
- Workplace preventive measures are established (physical distancing, hand-washing facilities, respiratory etiquette in place). New policies and protocols are necessary.
- Risks from across borders are managed and mitigated.
- Communities have a voice and are engaged in the transition.
As European countries have already started to implement their own strategy based on national priorities and goals (see BBC, Guardian, WE Forum), the European Commission (EC) has announced a Joint European Roadmap towards lifting COVID-19 containment measures. The document emphasises the need for a common approach among the Member States in their exit strategies and points out three principles inline with WHO’s recomendations:
- Science based decisions: any decision to lift restrictions should be based on science, have public health in its center and consider all social and economic issues.
- Coordination across Member States is necessary.
- Respect and solidarity between Member States remain essential.
Unfortunately, despite the agreement in principles, so far the coordination at the EU level is far from optimal. Where everybody agrees though, is that all countries need to ramp up their diagnostic capacity. So more and more testing. Which brings us to the next point.
Aggressive Testing helps but can we do it?
You don’t need to be an epidemiologist to understand the value of diagnostics. If you cannot test, you do not have enough data and you cannot reach informed decisions. The importance of testing is highlighted in this article in Our World in Data. In all the countries that were lauded for “flattening the curve” quickly, even without total lockdowns an aggressive testing strategy was a very important component (South Korea, Iceland). However, it’s easier said than done. South Korea with a population of 51+ million, was much better prepared for the crisis after the MERS outbreak of 2015 (WEFORUM, Mar 2020). Iceland on the other hand is a relative isolated island with less than 400K inhabitants. Not exactly comparable.
So far, we can summarise the available diagnostic tests into 2 categories: those that detect and confirm the virus and those that detect any antibodies.
- Detect and confirm the virus: detects if someone (symptomatic or not) has the virus: Molecular (RT-PCR) Tests and Rapid Tests.
- Antibodies: reveals if one has developed enough antibodies to the virus.
COVID-19 RT-PCR Tests
The RT-PCR (Real-Time Reverse Transcription Polymerase chain reaction) test detects the virus. It is so far the golden standard of COVID-19 testing and it uses swabs from nose and throat. See how it works here. The test provides acceptable results with specificity and sensitivity of more than 90%. However, in order to conduct it, certain WHO protocols need to be followed, in capable and certified labs, which makes it necessary and testing may take a few hours. Given the logistics, the overwhelming volume and the need for labs this method poses important restrictions for mass testing. (See also COVID-19 Diagnostics Explained, Asian Scientist Magazine, Apr. 8)
COVID-19 Rapid Tests
In contrast with molecular tests, Rapid Test Kits, can provide results in less than one hour. Although not as accurate as molecular, rapid tests may take less than 30 minutes (often much less) to give a result. These tests are simple to perform and interpret and do not require any expensive equipment or labs. They can be performed in the field. Rapid tests are of 2 types:
- Detect viral components during the infection
- Detect antibodies that appear later as part of the immune response. This is called serology.
ECDC provides a short overview of the rapid test situation for COVID-19 Diagnosis (ECDC, Apr 1). New tests are added every day and you can see the pool in CDC’s website (for USA approved) and in FIND (a WHO Collaborating Centre for Laboratory Strengthening and Diagnostic Technology Evaluation). Till the time of writing, FIND’s Pipeline had 83 tests listed while CDC had 41. (FIND also published an evaluation of the Molecular tests).
The problems
Despite the abundance of candidates not all of them are either approved or adequately tested. Global demand forced health authorities to revert to emergency procedures to ensure supply. The Berlin company Charité, worked with academia in Europe and Hong Kong and developed one of the first molecular (RT-PCR) tests. This test approach was adopted from WHO which distributed 250.000 test kits in January. South Korean company Kogenebiotech also developed a molecular COVID-19 test kit. Chinese group BGI also jumped quite early in the game, receiving approval from China’s authorities. CDC however, distributed tests that did not work properly to nearly all of the 100 state and local public health labs (NYT, Apr 18). Many countries in Europe have faced similar problems, discarding thousands of tests from China that proved faulty (WT, Bloomberg).
The Good News
The global impact of the pandemic, led to an unprecedented collaboration of the scientific community with new developments and progress that pushes the frontiers of science almost daily. (see the beautiful infographic below).
It is more than certain that science will find the solution. We are not yet exactly sure how long it will take, but my bet would be sooner rather than later.
So Now What?
After about 1 month of social distancing and lockdowns, most countries in Europe start to consider some kind of reopening. It seems that, in terms of deaths at least, the worst is behind us, but the economy struggle we will face, will probably be much worse than anything we experienced so far. This is what most analysts repeat tirelessly.
Well, in Greece at least, we were just exiting one of the worst economic crisis of our modern history. We endured 10 years of austerity, political upheavals and a disastrous and partizan populist movement. However, so far it seems that we handling the crisis surprising well. [See Reintroducing Greece]
Yes, the European Union did not respond with the greatest solidarity we expected but it was an unprecedented situation and although we are not happy with its response, we understand that we now need it more than ever.
We will have to adopt (for some time at least) different habits (less hugs, more hand-washing), accept new procedures (as we did after 9/11), learn new skills (as we had to, during the financial crisis). We will need to create new strategies, find new practices, fight our worst fears, reject populism and easy solutions. Work smarter, innovate, learn, endure. In the end Harari is right: we can choose what the world will look like after COVID-19.
Latest Updates
Since the original post on Apr 20, more and more countries consider restarting their economy and the discussion on massive testing is gaining more and more time both in policy committees and in the news. The Economist had a piece yesterday on this (How to build and deploy Coronavirus testing at unprecendented scale, The Economist, Apr 22).
