How Germany got down to testing
ON FEBRUARY 25, when much of Europe still believed it could avoid the coronavirus crisis, news broke that a 47-year-old man had tested positive in Germany.
As authorities raced to track anyone the sick man had been in contact with, a terrifying picture emerged. He had spent the previous 10 days at carnival celebrations where he could have infected hundreds of people.
But experts now agree Germany did one crucial thing right at that moment. It started testing everyone who had been in contact with the infected man.
Little more than a month later, Germany is now testing around half a million of its citizens every week.
Britain, meanwhile, is lagging far behind with only around 8,000 people tested per day. Ministers and public health officials are now facing growing pressure to explain why this country, one of the world’s leading scientific nations, is struggling to match its European neighbour.
There are two striking facts about the situation in Germany. One is that the death rate is far lower than anywhere else, with only 858 fatalities despite 77,558 confirmed infections – a rate of just over 1 per cent.
The other is that Germany has conducted far more tests than anywhere else, at least in Europe. In fact, Germany is conducting so many tests no one knows the real number.
Professor Christian Drosten, the virologist in charge of the country’s response, estimates it at 500,000 a week.
But only positive tests have to be reported to the authorities, and the true figure could be even higher.
“The reason we have so few deaths is because we do a lot of tests,” Prof Drosten, said last week – and if he is right, it could be cause for hope that the German figures are closer to a true death rate. In Britain, the picture is far from clear. In the early stages of the epidemic, ministers and public health officials decided to follow a different strategy: to mitigate rather than suppress the disease.
Widespread testing would not be required, it was decided, given the majority of the population was predicted to catch the virus anyway.
Instead, priority was given to relieving pressure on the NHS by buying up much-needed ventilators and making space for intensive care beds.
On March 12, all community contact tracing was abandoned as it became clear the virus was spreading freely.
Crucially, laboratories across the country were not readied for action.
Initially, only the Public Health England main facility at Colindale was charged with processing swabs. Later, as the virus progressed, 11 more PHE labs were called into action, and 29 networks of labs in NHS hospitals.
But when Imperial College modellers warned the “herd immunity” strategy risked causing 250,000 deaths, the strategy swiftly changed. Now the Government saw that it needed to “test, test, test”, as the World Health Organisation (WHO) put it. The fear now, however, is that the about-turn came too late. At that stage Germany was already able to carry out thousands of tests due to the decentralised nature of its health system.
Test samples have been sent to a network of 176 public and private laboratories across the country for analysis – and there are plans to switch over to veterinary labs to increase capacity further. Not every lab uses exactly the same equipment, but they all conform to the official guidelines.
“We have a culture here in Germany that is not supporting a centralised diagnostic system,” Prof Drosten told NPR radio. “So Germany does not have a public health laboratory that would restrict other labs from doing the tests.”
This is made possible by the way the German healthcare system works. There is no central, Nhs-style health service, while clinics and hospitals are independent, funded by public health insurance.
Britain, meanwhile, has struggled to mobilise the vast network of laboratories needed to carry out testing on a mass scale.
There are not as many labs in Britain, as the strength of the NHS means the private health market is smaller.
But as the former WHO director Anthony Costello has pointed out, at least 44 registered virology labs could be used to ramp up testing. Leading scientists from Oxford University and the Francis Crick Institute have offered their services to no avail so far.
Experts here have raised concerns that British authorities are too focused on the uniformity of results, and have been reluctant to farm out work to smaller, private laboratories that might use different machines and standards.
Instead, Public Health England and the Department of Health have attempted to build up capacity by strengthening centralised super-labs, with closely controlled testing facilities and identical PCR machines used to develop the tests.
The most pressing problem facing British officials is a global shortage of the crucial reagents needed to replicate the virus and therefore produce thousands of tests. Germany, of course, along with other countries, moved quickly when the virus emerged.
Doris-ann Williams, chief executive of the British In Vitro Diagnostic Association which represents the diagnostic
industry and is helping the NHS ramp up testing, said she feared Britain was now at the “back of the queue” for the much-needed substances.
“The fact is that the major centres who can do this kind of work are in Germany and the US. We have a much smaller capability. We have laboratories capable of doing the work but not yet to scale it up at the level needed.
“Unfortunately we have been left somewhat at the back of the queue because other countries have got their orders in before us. I don’t wish to be critical of the Government – but it’s true that if we had got our orders in earlier then perhaps we would be in a slightly better position.
“Some countries are taking a more nationalistic view and keeping the reagents for themselves. But generally it’s a simple commercial issue. The companies are processing the requests in the order they were received... the reason they are delivering to certain countries is simply because they asked first.”
Boris Johnson is now personally leading efforts to secure the reagents for Britain, and spoke with major manufacturers last week.
Ultimately, Germany has enough testing kits because it got its act together early. German scientists developed a test for the virus as early as Jan 16, before the WHO had declared it transmissible from person to person.
German scientists were able to develop a test quickly because doctors and academics worked together with the private sector without waiting for the government to act.
Olfert Landt, a biotech entrepreneur, set his company TIB Molbiol to work alongside Berlin’s Charite hospital to develop a test.
Tests are still confined to those who are showing symptoms or have been in contact with an infected person, but Germany has been rigorous in pursuing chains of infection, and has carried out repeated tests on those it considers at high risk.
Germany’s insurance-based health system is not as wary of the profit motive as the NHS, and the public insurance funds agreed to pay for testing in February.
The tests are also available privately in Germany for around €200 (£176), and many are believed to have been carried out by employers for at-risk staff. By March TIB Molbiol had produced four million test kits that were being used around the world.
Another key element was the Robert Koch Institute (RKI), a publicly-funded German health authority set up almost precisely for a moment like this.
Germany also took a different approach to primary care. There, if a person is concerned they might have the virus, the official advice is to contact a doctor.
Ordinary GPS can order the test, and they can even do so over the phone. Germany was one of the first countries in Europe to set up drive-through test centres.
“One thing Germany has got right is its aggressive approach to testing,” said Dr Shreemanta Parida, an expert in infectious diseases based in Berlin. “But it’s not just that, it’s also the guidelines for doctors on when to order a test.”
In Britain, however, GPS were initially given strict guidelines only to refer suspected coronavirus patients for testing if they had been to an at-risk area, or had contact with a confirmed case.
At that stage, swabs sent to the PHE facility in Colindale were destroyed if they did not meet the strict criteria, and the chance to closely monitor the spread of the disease was lost.
Meanwhile, thoughts in Germany have already turned to the next type of test: the antibody tests that will be necessary to find out if people have immunity to the virus.
At the moment it is not clear how long those who recover from the virus, or are infected but do not get ill, retain some form of immunity.
A study is set to begin this month of 100,000 volunteers in Germany in order to develop a test for antibodies.
‘We have been left somewhat at the back of the queue because other countries have got their orders in before us’