The Problems With Testing And Case Statistics For Covid-19 By Nathan Hoturoa Gray
To begin to understand disease transmission in a country requires adequate testing of your population with properly vetted, accurate tests. As the world struggles to find what 'adequate percentage' of the population is necessary, (estimates predict that the lower end of the spectrum requires 750,000 tests per week in a country like the United States up to as high as 1-2 million tests per day), it is likely that we are only seeing the tip of the iceberg with regards the real numbers of affected by this virus globally. Ultimately, the inability to fulfill the requisite diagnostic testing measures in a timely fashion has been a major reason for the explosion of the Covid-19 virus throughout the world. So what has gone wrong? What have we learned and where were the failings in our initial testing regimes, bureaucratic responses, and the ability to gather correct statistics globally to inform key decision makers on the severity of the health crisis unfolding and thus the measures on how best to respond?
With initials alarms being raised from the pandemic crisis in China, South Korea, and Italy; the USA needed to mount a rapid response. In the beginning, fearing a global shortage of testing kits and reagents, the US Federal Government decided not to utilize the World Health Organization (WHO) test-kits, and instead had the Center for Disease Control (CDC) develop their own version. The CDC lab facilities in Atlanta violated manufacturing practices when assembling the kits, which resulted in contamination of one of the three test components used in the detection process. Despite being faulty, CDC officials took weeks to address the issue and fix the kits, yet the Trump Administration continued to rely on these results when forming health policy for the country. This frustrated academic, hospital and public health scientists who demanded alternatives to the CDC test, but were prevented from doing so by the Food and Drug Administration's (FDA) wieldy bureaucratic requirements. With limited testing available, the initial decision was to test only a narrow set of people, (those who were exhibiting symptoms and had also traveled to China, or those that had come into contact with a confirmed case). This is despite the fact that the pathogen had by this point almost certainly spread into the general community. The limited testing left top officials blind to the true dimensions of the outbreak.
Testing was also very slow in the United Kingdom, potentially resulting from the right wing led Government's initial strategy of a potentially devastating herd immunity approach. With herd immunity, the disease is allowed to run rampant, and those that survive would hopefully pick up long lasting antibody immunity to the virus to protect them from future outbreaks. Those immune individuals then also break the chain of infection, creating a protective environment to reduce the risk to non-infected people. For some diseases this requires upwards of 95% of the population to be infected, and also relies on the assumption that those with antibodies are protected from subsequent infections. With millions at risk of losing their lives, (estimated at up to 16 million in the UK alone), the strategy was severely criticized globally, especially as hospitalizations surged. The herd immunity approach was also attempted in Sweden which declined to institute any major lockdown social isolation measures and continues to do so to this day. The Swedish death rate has risen rapidly to over the 3650 mark, far higher than Norway's 232, Finland's 296, Denmark's 534 and Iceland's 10 as of mid-May statistics, (highlighting the dangers of the herd immunity strategy on even smaller populations.) Furthermore, GDP loss statistics just coming out from those countries shows that despite leaving its cafes open, Sweden's GDP will go down up to 9.7% due to a breakdown of the manufacturing supply chain and loss of global exports they are so reliant on. This is compared with Finland's 6%, Norway's 5.5% and Denmark's 6.5% loss of GDP estimates. Further to this, Sweden has still only recorded just under 30,000 corona-virus cases, so with already well over three months now into the virus, it would take years and years to reach any valuable level of herd immunity for its 10.5 million population.
It is interesting to note that Simon Bridges, (recently ousted) National Party Leader of New Zealand also initially propagated the herd immunity approach when Boris Johnson first touted the idea which could have seen up to 16,000 cases and potentially 600-1000+ deaths through April if New Zealand had followed suit. The UK soon backtracked on its herd immunity approach embracing the lockdown model, especially as hospitalization numbers grew including their Prime Minister, Boris Johnson, who required attention at the Intensive Care Unit. Luckily a bed was available to him, which was the greatest risk under a herd immunity approach. The death rate for ICU patients in general is exceptionally high (approximately 20%), especially if one is forced onto a ventilator to facilitate breathing to give time for the body to develop antibodies to fight off the virus before one's organs fail altogether. Fortunately the 55-year-old Johnson did not get to the ventilator stage, and ironically was saved by the work of nurses from New Zealand and India, whom he openly praised (despite their government's strong policy stance against immigration). Demonstrating that the powerful are not immune, the future King, Prince Charles, also contracted Covid-19. Albeit a mild form, Prince Charles was asymptomatic and was just one day off from meeting with the Queen, whom at 93, was at massive life and death risk had she contracted it. Prince Charles' age also placed him at sufficient enough risk to have his son Prince William worry about the realities of being second in line to the throne.
The UK were hoping to ramp up testing to 100,000 a day by the end of April, but Public Health England was unable to spread the work initially to all the university and other public health labs throughout the country. By the end of March they had ultimately only reached 10,000 tests a day. The lack of early testing gave the government an erroneous perspective on how the virus was tracking throughout the region - which also led to a delay in setting up a much needed shutdown as the death rate was set to soar. By April 25th the testing regime was still labouring towards just 20,000, sadly the same number as the country's overall death rate at that time.
As an aside, it is also interesting to note that when the UK Government looked into securing specific antibody tests on the 11th of April to help show exactly how many people had actually caught the virus (and since recovered), the initial 2 million testing kits secured from a company in China for $20 million were all faulty. It must be stated here that the phase 2 'antibody testing approach' is still a risky aspect of the herd immunity approach, as research has yet to uncover exactly how effective or how long antibody immunity lasts in the body to protect from future infection. Although Measles gives you lifelong protection after catching and surviving from it, other coronavirus' like SARS and MERS tend to fade after to 2-3 years immunity, whilst the four other known coronaviruses, (which cause varieties of the common cold), just provides months of antibody immunity. Other countries such as the Czech Republic who also purchased testing kits from China found that 80% of their tests were unreliable as well, (as reported by their major news organisation Seznam Zpravy.) With 1.83 million Euros spent on the 300,000 rapid covid-19 test kits many false positives as well as wrongly negative results had come to light after being assessed by hygienists from the University Hospital Ostrava.
Testing continued to be very slow in the United States, with President Trump minimizing the existence and impact of Covid-19 and its spread. After inserting travel restrictions on China on Jan 31st, he stated publically that 'the virus was completely under control' despite warnings from US Intelligence and his Trade Adviser Peter Navarro to the contrary, not to mention Joe Biden putting an op-ed in USA Today on Jan 27th stating 'that with 2,700 affected in China and over 80 dead, the Corona-virus will get worse before it gets better.'
Trump then doubled down on his anti-alarmist views stating that the virus was a hoax made up by the Democrats, misinformation that was widely spread by Fox News who only retracted these statements over ten days later. Despite Health officials wanting social distancing to be exercised by mid February, Trump plowed on with his original "deny at all costs" strategy holding numerous political rallies and predicting that Covid-19 was "just like the Flu" and would be gone before establishing itself. It was only until March 16th when the stock marketed had plummeted to over a third of its value, (bigger drops than even the 2008 crash and the Depression of 1931), that Trump recommended that Americans not congregate in groups of more than ten. Roughly 2500 Americans had died by the end of March, yet President Trump still floated the idea of opening the country again by Easter. Towards the end of April over 60,000 Americans had died, (over twice that of Italy, the second leading country for fatalities), and yet Trump still officially encouraged the economy to be fully reopened by May 1 not to mention a series of tweets enticing conservative groups to protest for their freedom to work. Many protests took place with some individuals brandishing semi-automatic weapons outside State Capitols in Pennsylvania, Michigan, Ohio, Virginia, Texas and Florida to mention but a few. As an interesting side note, Denver, Colorado had protests during the 1918 Spanish Flu epidemic to reopen the state up after a 5 week lockdown. Reopening on Armistice Day November 11th 1918, the decision resulted in a second major surge of the virus killing over 8000 people (which were more Coloradans than had been killed in World War I altogether.)
America eventually performed 5 million tests as of the 25th of April - over 90 days after Covid-19 had reached the country. While 5 million is more than any other nation in the world, per capita, America was only achieving 15 tests per 1000 people, compared with Italy's 30 per 1000 people who was Europe's leading viral hotspot through February, March and half of April. (Italy's testing regime equates to approximately 20,000 tests per day, easily eclipsed by the wealthy United Arab Emirates which is the highest per capita testing nation in the world currently with almost 80,000 tests completed per day.)
With America's first confirmed case of community transmission falling on the 29th of February (but may have been as early as mid January as discussed below), Trump had also wasted the majority of March to secure vital levels of Personal Protective Equipment (PPE) for Public Health workers. The Federal Government had completely run out of masks and was asking medical staff to re-use masks and gowns (often using garbage bags instead) as well as having a massive shortage of ventilators. Individual States who had secured contracts with Chinese, German and other global providers for these PPE necessities had them usurped by the Federal Government itself and placed where President Trump deemed them most necessary. This total breakdown in governance not only contributed to the massive rise in cases and deaths throughout March and April, (including the infection and death of thousands of key health professionals), but led to enormous bipartisan criticism of the President, in particular by Democratic Governors like Gretchen Whitmer in Michigan, and Andrew Cuomo in New York as vital PPE supplies were sent instead to Republican Governors that kowtowed to Trump instead.
As Governors fight for resources against other states, it becomes a capitalistic bidding war with prices surging and some states clearly losing - with the ultimate winners being the companies producing PPE. It is worth noting that this "supply and demand" crisis was foreseeable and avoidable. In 2005, US President Barak Obama raised the issue and called for greater preparedness surrounding the availability of PPE in the inevitable advent of a pandemic crisis. This was discussed in Trump's and Obama's first meeting in the White House, but Trump chose to ignore the important advice being passed on -interested more so in bragging about the clearly inflated numbers he had at his inauguration instead.
The unique health system of the United States also presents a challenge for testing compliance. Socio-economically vulnerable areas are the hardest hit, and would also be the population least likely to have affordable, preventative health insurance. This means to achieve a Covid-19 test, an individual must pay between $1300.00-2600.00 USD - severely limiting the testing regime. This was changed when the 2.3 trillion stimulus bill from the US government was finally passed through Congress making testing free - albeit hospital stays were still being charged for - making it out of reach for the 30 million uninsured Americans (in addition to the 33+ million Americans recently furloughed or laid off, many of them also losing their health insurance packages which were tied to their jobs.) It always boggles the mind that the richest country in the world is one of the only developed nations on the planet not to offer its citizens free health care. A prime candidate for mass devastation by a relentless, respiratory spread pandemic.
Bad Statistics Globally
When trying to establish informed policy as to how best slow the spread of the virus, initially it comes down to the number of cases, testing numbers, hospitalization and death rate to help provide evidence for such analysis. Most third world countries cannot even afford a testing regime except for humanitarian / public health work being done by the UN if they are lucky, so their statistics are essentially useless to form any viable opinion on global health policy. For example, news video showed two doctors entering an Indian Slum to conduct testing and being chased away with rocks and sticks by a wild mob. This is often the case with UN Health workers in third world countries like Africa working on the Ebola virus as they are seen with so much suspicion by locals, (because once they take a patient away to stop the spread - they often never return). Ultimately, there is no realistic way to assess exactly how far the disease has penetrated into the population at large in these developing countries, especially where testing has been so low especially in places like India, Pakistan, Bangladesh, Sri Lanka, Afghanistan, Maldives, Nepal and Bhutan - the overall death total for all these countries combined a miniscule 3766 as of May 14th. (Despite housing a quarter of the world's population!)
As an example, in Ecuador, dead bodies were piling up in the streets due to Covid-19 because of the myriad of homeless victims as well as families not knowing what to do with their loved ones given all the morgues and funeral companies were completely inundated. Ecuador's statistics showed for the month of late March and early April that 7000 more people had died in the country than figures for the same timeframe in 2019, (and thus likely attributable to Covid-19), although their official death count due to the virus at the time was a paltry 450.
Even in the USA, numbers were just being counted by those that had officially gone through the hospital system, yet thousands of casualties had never made it to hospital at all. In New York there had been an alarming surge in the death rate of younger and middle aged people stealth killed by the virus at home due to it attacking the neurological systems of its victims and causing a deadly stroke. China and much of Asia's statistics and resulting strategies have been seen as world leading in the fight against the virus - yet have simultaneously been seen by some with relative suspicion given many of their numbers are incredibly low when compared with their population sizes and the carnage going on in the United States and Europe. For example, Vietnam had no deaths, Taiwan 4 deaths, Singapore 12 deaths and Hong Kong only 4 deaths by April 25th despite housing densely inhabited populations, and living on or close to China's borders.
China's numbers itself remained stagnant after the initial wave swept through Wuhan and the wider Hubei Province. Although the virus was arguably 'stamped out' by the Communist's Party's strict yet effective Authoritarian shutdown where 81,000 cases and 3100 deaths were recorded, by April 15th the number in Wuhan was doubled, raising the overall death count in China to 4200 deaths. This figure, coming seemingly 'out of fresh air' was based primarily on the deaths they had missed retrospectively due to the intense pressure on the hospital system at the time, (and all the pressure from the USA and the rest of the world arguing that they were not showing their true numbers.) Furthermore, Journalists from the Associated Press also uncovered the fact that the Chinese State delayed 6 days in January when having full knowledge of the virus and its fatal effects before informing the Chinese populace at large. They only instilled precautions just before the Chinese New Year, (where the whole country shuts down and everyone leaves from the cities to head home to their rural communities), which would have been a public health disaster. Many left nonetheless on the holiday but were unable to return to provinces like Hubei, Beijing, Chengdu and Shanghai which had subsequently been shut down over the Chinese New Year break. Meanwhile, and to China's immense credit, they were able to increase hospital capacity by building two new hospitals, (staggeringly in just ten days), during the brunt of their health emergency but amongst this infrastructural building frenzy questions are still being asked whether the country is still putting forward proper statistics, (not to mention the conspiracy theories over the virus escaping from a medical lab in Wuhan.)
Numbers in Africa in general have been increasing very slowly, the majority of Sub-Saharan countries officially stating that they have still less than 1000 cases and averaging less than a 100 deaths as per mid May. The optimistic view is that given the travel bans worldwide, the transmission into Africa may have been slowed especially with the knowledge and experience African governments have had fighting Ebola and utilizing these strategies to keep the virus at bay; however, the more pessimistic view is that the slow case numbers are due to the lack of actual testing. Furthermore, looking at the high numbers of deaths in Algeria and Morocco, there is no doubt that the virus had spread south from Covid-19 ravaged Spain. A Guardian Journalist was also expelled from Egypt for reporting on a document that stated Egypt's numbers were way higher than the numbers the government was submitting and picked up by John Hopkins University - the official global tally. Observing the gradual spread through the Middle East and Arabia over the month of April has showed that the virus is certainly making its way through these parts of the world, (Saudi Arabia currently recording well over 1000 new cases a day hitting 90,000 cases in early June), although one can never fully trust their statistics given their death tally of only 534. For example, Iran, the first hotspot in Arabia initially stated that the virus was not affecting them at all. However, the Minister of Health who was making the statement to local and international press, (surrounded by many of his governmental peers), was clearly showing signs of having caught the virus - sweating profusely on television. As he went into quarantine the next day, the vice premier and a whole hoard of other politicians and media had picked up the virus as cases surged to over 165,000 with 8000+ deaths by June 5th, 2020. One other Arabian country that requires more attention is definitely Qatar, which is currently showing over 63,500 cases yet only a miniscule 45 deaths, which constitutes a case to mortality ratio of less than .1% - well below that of countries like Italy at 14.5%, France 15.4%, UK 14.2%, Spain 11.3%, Sweden 11.1%, USA 5.8%, Brazil 5.6% and Russia at 1.2%.
In Africa where disease, hunger and other ravages are common, (with up to 5,000 people dying a day purely due to a lack of sanitized water), it is clearly a lot more difficult to attribute deaths at this time simply to Covid-19. This is compounded by the economic and food insecurities caused by border closings from the virus. The loss of tourism, humanitarian aid, and trade will no doubt result in Covid-19 related deaths among individuals whom never see the disease. Although the reality is, were it to make its way into any of the many slums or migration camps where health and sanitation is so poor - it would absolutely decimate these populations- possibly without any way for the local governments to accurately track these numbers. These are the raw realities of having a human population nearing 8 billion and its ongoing and unsustainable plundering of finite resources.
The disease has also hit Brazil hard, essentially the epicenter in South America as President Bolsonaro, (named the 'Denier in Chief'), due to his utter disregard for Covid-19 and his desire to keep the economy open at all costs. As a result their Covid-19 testing has been less than adequate currently set at 32 times less than the United States is achieving. Despite only conducting just 340,000 tests the number of affected inhabitants is a staggering 163,500 - a positive test rate of almost 50%! (Compare this with New Zealand which has conducted over 200,000 tests and getting a strike rate of only .05% of positive cases per test.) The figure for those affected in Brazil must be astronomically higher in reality, especially as the death toll surged above 10,000 come May but still way below the fatality trajectories demonstrated by Europe and the USA . Ironically Bolsonaro's chief advisor was carrying the disease while he and his political cadre were visiting Trump in the White House back in March which led to Mike Pence and Donald Trump being tested for the virus on numerous occasions (34 US Senators, House Representatives and state legislators have since picked up the virus).
On the other extreme, Belgium, which has the highest rate of death per capita in the world, has taken a death toll counting measure that includes not only those that died in hospital, but also those that perished in rest homes as well, even though they hadn't been specifically tested for Covid-19. Open to criticism by Belgium's political elite due to the negative light in which the country gets framed, health experts adamantly held onto their liberal counting system to provide an over awareness of the numbers at stake, rather than the risk of limited awareness raised by nations that were only counting formally tested deaths in hospitals. This policy was also eventually mirrored by New York whose daily death rate rocketed up more than 3,700 in one day in mid April when they decided to count the deaths of people that were presumed to have Covid-19 but were never tested. (Spiking the daily US tally which was averaging 2,000 to a staggering 6,000 deaths.)
One issue to keep in mind is the fact that the standard number of deaths that would normally occur each month during the same time in 2019 have not been used as one of the standard metrics to examine the monthly death-rates under Covid-19 in 2020 on the John Hopkins website, which, as such a widely utilized resource globally could have had an immense political impact. The Financial Times listed the rise in deaths over the period up through April 2020 and found that the UK had 42,900 excess deaths and France had 20,100 more deaths than normal, (yet not attributed to Covid-19.) The list also included Italy at 24,500 extra deaths (a 55% rise), Spain 32,000 extra (at a 60% rise), Netherlands 7,700 extra (at a 52% rise), Belgium a 5,200 rise (at 60%), Sweden at 2,300 (a 28% rise), Turkey at 3,800 (50% rise) as well as Portugal, Sweden, Germany and Switzerland also recording over 1000 more deaths than normal. All up it has been suggested that 60% of extra deaths throughout Europe and the USA have not been counted in official tallies, and poor countries' data would clearly be way worse. For example, figures in March for burial statistics in Jakarta, Indonesia's capital suggest that they may have only captured 5% of the true toll of Covid-19 deaths. Furthermore Hugo Lopez-Gatell, the Deputy Health minister spearheading Mexico's response to the outbreak recently told Reuters that the country's coronavirus death toll is way higher than the official count which as of May 10 stood at 3350. And one cannot go past mentioning Russia, who is currently 3rd in the world for confirmed cases at over 440,00 (even higher than the UK, France and Italy), yet posting a paltry 5384 fatalities as of June 5th. Moscow and the northern oil fields in the Russian Arctic have been particularly hard hit with the virus, putting their major prospecting projects at great risk, and of course, trust in Putin's official death tally. Bloomberg news also states that the poorer regions in the south that have limited hospital capacity have been hit hard as well, but have not been officially counting mortality numbers. St Petersburg also issued 1552 more death certificates in May 2020, than in May 2019 yet the Covid-19 death toll for the city was only 171. Furthermore the death rate for April in all Russia was 18% higher than the equivalent month in 2019 so maybe Putin just left his abacus back at home?
The most recent statistical evidence coming out of Yale School of Public Health show that for the month of March and the first two weeks of April there were 37,100 excess deaths from the same period last year all of which could potentially be attributed to Covid-19 yet not showing in the USA's current death tally which would now be well over 100,000. If the numbers in the USA had been portrayed in this way, and the sheer escalation illustrated, surely the number of protests arising from right-wing conservatives in the USA outside State Capitol buildings wanting the lockdowns to be dropped and freedom installed would have been even more harshly criticized, or never actually happened at all? Because there hasn't been enough testing to determine the exact numbers of Covid-19 caused fatalities - government leaders should be studying the estimates of excess deaths in their communities and basing consequential decisions about reopening businesses and social activities on those figures, rather than strictly using reported coronavirus figures that are often incomplete and misleading the Yale School of Public Health argues.
As it turns out, according to a CNN article on April 22nd, new autopsy results showed that two Californians actually died of Coronavirus in early and mid-February - up to three weeks before the previously known first death in the USA. The two deaths in Santa Clara County happened on February 6th and 17th, and not February 29th in Kirkland Washington as was initially deemed the first. (The deaths occurring in early February, would have contracted the virus in mid-to-late January). The two in California had no known travel histories to China or anywhere else, and thus presumed to have caught the virus through community spread leading to the high possibility of both significant case number and death undercounts. Two studies in Santa Clara and Los Angeles Counties stipulated that the suggested number of people infected in these areas is dozens of times higher than officially reported. The Los Angeles County study estimated between 2.8% and 5.6% of the population - 221,000 to 442,000 people, had Covid-19 antibodies, based on drive-through testing conducted on April 10 and 11. That would have been 28 to 55 times the number of cases that county officials recorded around that time.
In Santa Clara County, the study estimated 2.49% to 4.16% of people there had been infected by April 1. That represents between 48,000 and 81,000 people - and 50 to 85 times the cases that county officials recorded by that date. Similar efforts to estimate local antibody prevalence has since launched in places like New York, Miami, and Colorado to ascertain case numbers to help improve projections and disease modeling to give a more realistic sense of how deadly Covid-19 really is, (or not) in different parts of the United States. The New York Times and Dr. Fauci Anthony, the top medical expert on the White House coronavirus taskforce have both strongly rebuked reports from Fox News stipulating that the death count is lower than the official tally of 85,000 in the USA. President Trump agrees with the official tally, yet Dr. Fauci believes it is now over the 100,000 mark. The New York Times also goes so far to state that the global total is twice that of the official numbers presented.
Only time will tell what new strategies will be entertained once many countries exit out of lockdown having lowered the hospitalization curve and further studies demonstrate the actual realities of the virus' spread. Yet without a current vaccine, (despite the worldwide race to secure one), nor full knowledge of the strength and duration of antibodies for those who have already survived the virus, (or hard evidence on the possibility of viral resurgence) - it is a 'new normal' globally as the devastating impacts of Covid-19 show its true face throughout the turning point that is 2020.
 Iceland was the first country in the world to test 10% of its population for the virus, [given its diminutive population of 346,000] so is a useful test case for understanding the virus' trajectory in Island nations given their adequately sourced statistical data.) It has currently tested nearly 17% of the country as of May 16 statistics and has only ten deaths.
 New Zealand's testing regime of 12,000 a day has produced over 200,000 tests thus far comprising 3% of the population or 30 per 1000 inhabitants and one of the highest rates of testing per capita in the world.
 Vietnam's strategy in particular has been highly praised by implementing early strict border screening measures, travel restrictions and mandatory 14 day quarantines, high testing rates and ongoing health checks, school closures, contact tracing and closing down of cluster infected regions. Independent testing throughout May shows that the numbers are in fact real.
 Saudi Arabia's military enemy, the highly impoverished nation of Yemen has been massively undercounting their cases and death tallies due to the rebels who control the north of the country threatening medical workers to remain silent on true counts and the ill-equipped hospitals down south turning away patients to die unaccounted for at home. Their official tally is 490 cases and 95 deaths as of June 4, 2020 but a myriad of social media posts acknowledging the high numbers of fatalities show infections to be in the thousands and the deaths in at least the hundreds. If all 28 million Yemenis were to get infected, there could be a total of at least 65,000 deaths.
 This is in complete contrast to what is going on in Nicaragua where the Guardian reports that the country's express burials have raised fears that General Ortega is hiding its death count which has been estimated by independent tallies to be over ten times the official rate. See 'Nicaragua's express burials have raised fears that General Ortega is hiding true scale of the pandemic' by Wilfredo Alberta, May 19, 2020.