What is happening in Slovakia and what lessons might it hold for the UK?
The UK’s response to the covid-19 pandemic has, on any measure, been unimpressive. In a recent assessment of G7 countries, it came out second worst in the cumulative number of deaths in relation to population, just behind Italy. It was worst in terms of the contraction of the economy. These facts were well known. What was new, and surprising, was that it had achieved these unenviable positions despite spending far more than most of the other countries. Using a measure based on the core budget deficit, it spent 80% more than the average among these industrialized countries, beaten only by Canada.
Faced with this predicament, it is understandable that ministers would look elsewhere for ideas. At first it was Sweden, with Downing Street seeking advice from its chief epidemiologist, Anders Tegnell. Sweden’s refusal to adopt the stringent measures imposed elsewhere had obvious attractions for a party committed to individual freedom, with ministers who had spent many years criticizing the “nanny state.” Unfortunately, as the evidence from Stockholm accumulated, revealing a magnitude of economic decline similar to that in its locked down neighbours, but at a much higher cost in lives, the attraction waned, finally evaporating when the second wave, which advocates for the Swedish model predicted would not happen, became apparent.
Now many in Westminster are looking to another country that is doing something different, in case there are lessons to be learned. In the course of a few days, Slovakia, a country with a population of 5.4 million, tested 3.6 million people for coronavirus—97% of the eligible population of people aged 10-65; finding over 38,000 people, 1% of those tested, positive. For Boris Johnson, a prime minister who has promised a “Moonshot” project, in which mass testing of the population would make it possible to escape a continued cycle of lockdowns and “save the Christmas holidays”, could this constitute a solution, or at least a means of assuaging the concerns of his restive back bench MPs? A small group of advisors was dispatched rapidly to Slovakia to find out.
As so often during the pandemic, it is important to look at the detail. For many months, successive claims by British ministers about numbers of tests, performance of contact tracing, procurement of personal protection equipment, and much else have not withstood scrutiny. Now, there are very different reports of what is being presented as the pilot of England’s own “mass testing programme” in Liverpool depending on whether you ask 10 Downing Street or Liverpool Council. So what is happening in Slovakia and what lessons might it hold for the UK?
First, the basics. Since 2014 Slovakia has had a comprehensive population register, with a single record linking different government functions. This means that the authorities know who should be tested. Following a pilot in four counties on 23-25th October, nationwide testing was conducted on the weekend of 30th October – 1st November. Everyone aged between 10 and 65 was asked to attend a testing facility. The testing facilities were operated by health personnel and volunteers, with logistic support from the Slovakian army, assisted by Austrian and Hungarian medical professionals. Over 40,000 people, including approximately 20,000 health workers, have been involved in across-the-board testing for covid-19. Testing was undertaken with rapid antigen tests manufactured in South Korea (BIOCREDIT COVID-19 Ag (RapiGEN) and Standard Q COVID-19 Ag (SD Biosensor), giving results within 15-20 minutes. Both are highly specific and have reported sensitivities of over 90%. However, these figures have been questioned, with one pre-print reporting a sensitivity of under 30% under laboratory conditions. It is possible that performance could be even worse, as it is thought to be somewhat poorer in routine use. Testing was voluntary, but those refusing to be tested were required to follow strict curfew measures for the forthcoming 14 days. Anyone testing positive, along with household members and any contacts during the preceding two days had to self-isolate or, for those who faced difficulty at home, stay in a state run quarantine facility. Only those with a negative test were given a permit allowing free movement. The police have conducted some random checks and anyone violating the covid-19 regulations could be fined €1,650.
A second round was conducted on the weekend of 6-8th November in 45 of Slovakia’s 79 counties, selected as they had the highest numbers of infections. They were mostly in the north of the country in areas bordering Poland and the Czech Republic. This time the positivity rate was 0.63%. The government plans to continue with repeat testing in municipalities with a prevalence rate over 1%. A next round of mass testing of the entire population, scheduled for early December, has been cancelled due to a shortage of tests. Slovakia’s testing programme is only one part of a larger package that includes a requirement for most people crossing its frontier to have had a negative test within the previous 72 hours. Slovakian ministers have hailed the exercise as a success, allowing them to partially reopen entertainment and hospitality venues, although only for outdoor eating.
So could, or should, Slovakia’s model be transplanted to England? A crucial question is whether it worked. The testing programme coincided with large reductions in cases, of up to 60% in some areas. But was this due to the testing programme or to the lockdown and curfew measures that preceded it? One month before the mass testing exercise, the country introduced a partial lockdown (a ban on gatherings of more than six people, restricting the number of customers in shops, and obligatory wearing of face masks in indoor and outdoor public spaces). Just one week before mass testing strict curfew measures were implemented. People were only permitted to leave their homes for a limited number of reasons, including going to work and essential shopping or taking children under 10 to schools and kindergartens. A pre-print analysing the results concluded that it was not possible to disentangle the effects of the testing and the lockdown, although the authors believed that the results were better than would be expected with either on its own, with isolation of contacts of those testing positive likely playing an important role. Thus, it seems likely that mass testing would have to be accompanied by lockdown, coupled with measures to support those isolating. In other words, mass testing is not a substitute for a lockdown, but rather a complement. Moreover, to work, it is likely to require far higher degrees of adherence to isolation than has been reported in England, where those affected have struggled to obtain support to assist them in isolating effectively.
There are also other concerns, England has no comprehensive accurate population register. Instead, the privatized testing system has relied on a credit rating agency to assess eligibility for covid tests, even though many people will be excluded. Experience in Liverpool indicates that very few people living in the most deprived areas come forward for testing. Second, although voluntary, the Slovakian restrictions on movement imposed on those refusing a test, backed up by checks of permits by the police, employers, or shop staff, would be extremely difficult to replicate, with the British police already concerned about the pressures they are facing when enforcing less restrictive regulations. Third, there remain many outstanding questions about the performance of the rapid tests currently available, with the Innova test used in Liverpool achieving only 58% sensitivity when self-administered. Fourth, there are questions about logistic capacity. With a population ten times higher than Slovakia, the challenge of procuring test kits would be enormous. Then there is the problem of finding the personnel needed to run the programme. Scaling up the Slovakian operation suggests a need for about 400,000 people. In Liverpool, as in Slovakia, support was provided by the armed forces, but Slovakia needed to draw up on the assistance of its neighbours, especially when it comes to medical personnel. This is not an option for a post-Brexit UK; a country that has seen a dramatic reduction in military personnel in the past decade. The government could, as is its usual practice, recruit one of the large outsourcing companies, but it may not be willing to contemplate yet another failure.
Slovakia’s achievement, combining lockdown and testing, was clearly impressive. However, the practical and political challenges of doing the same in England are probably insurmountable. As infection rates are already falling, there may be better ways to use the vast amount of resources that would be required. A good start would be to fix the dysfunctional testing and tracing system and provide meaningful support for those who must self-isolate.
Martin McKee is professor of European Public Health at the London School of Hygiene & Tropical Medicine and a member of the Independent SAGE. He writes in a personal capacity.
Iveta Nagyova, Faculty of Medicine, P. J. Safarik University, Kosice, Slovakia. She is the President of the European Public Health Association and a member of the WHO Technical Advisory Group on Behavioural Insights and Sciences for Health.
Competing interests: None further declared.