Test, Lockdown, Test: Prescription for Small and Island Communities

All the lockdowns and social distancing in the world aren’t going to shorten the pain of this pandemic or save our hospitals unless we add a missing ingredient.

We must test, test and test again.

We must isolate symptomless carriers who drive the pandemic.

We must also keep those with mild symptoms at home, and away from hospitals.

We must break the demographic chain of infection which appears to travel from symptomless adults to the vulnerable and the elderly with medical complications.

And we can only do that by testing everyone every two weeks, until the infection rate is zero.

That’s the powerful and radical public health message coming from a small town in northern Italy with just 3,300 people.

It disobeyed the rules, and had a different ending than the rest of northern Italy.

There the pandemic flooded hospitals and killed thousands of people with a case death rate of eight per cent.

“We were able to contain the outbreak here, because we identified and eliminated the ‘submerged’ infections and isolated them,” recently explained Andrea Crisanti, an Imperial College microbiologist, to the Financial Times.

The people of Vo stamped out the virus, for now at least, “through extensive testing of both symptomatic individuals and all of their social contacts — including relatives, friends and neighbours.”

As a result Vo stopped the contagion before it had the chance to grow exponentially — and, most importantly, identified the symptomless carriers before they passed it on to other people.

By doing so, it also kept the death rate low at one per cent or less.

Given these results, Vo offers a revolutionary anti-COVID-19 model for island, Indigenous, rural and northern communities across Canada that still have small community infection rates.

The story of Vo

On March 3 local authorities started to test every inhabitant of Vo, located just outside of Venice.

Meanwhile many politicians were complacent and even encouraging people to not change their habits.

In contrast Luca Zaia, the governor of Venta, where Vo is located, pushed to test like crazy in his region. This went against WHO recommendations (they later changed) and national policy that reserved testing people for people with symptoms.

The government argued that testing folks without fever and coughs was a drain on national resources. That’s was Canada’s model too — though now it is boosting testing, but not fast enough.

Unfazed by the criticism, Zaia acted.

He reasoned more testing would identify the carriers and slow down the pandemic. And he was right.

By failing to test adequately most nations are now blind to the progress of COVID-19. They do not have a real picture of infection rates or how fast the virus is spreading.

They don’t even know which age groups are spreading the virus. In South Korea, which tests the most and has also slowed the virus, healthy people between 20 and 30 years of age with no symptoms appear to be the primary carriers.

One of Italy’s very first to die of COVID-19 was a 78-year-old man in Vo on Feb. 23.

That death unsettled the small community. With Zaia’s support, Vo started testing on March 3.

Meanwhile the University of Padua with the aid of the Red Cross and Veneto region saw an opportunity to a study the history, spread and risk of infection.

In the first round of testing the authorities found 90 cases, an infection rate of three per cent in the community.

The majority of the infected, of course, had no symptoms.

That’s important. A recent Science journal study on the Chinese outbreak found that 86 per cent of all infections were never documented as cases because these people presented no symptoms.

Moreover “undocumented infections were the infection source for 79 per cent of documented cases.” That’s why the virus spreads like lightning.

The village locked down. The infected, with or without symptoms, stayed at home.

Those combined measures (mass testing, isolation of the infected, and general lockdown) slowed and eventually broke the chain of infection.

Nine days later the authorities tested everyone again. (Remember current tests aren’t sensitive enough to catch people early in the infection stage, and many carriers can be missed.)

This time the authorities found only six infected people — a 0.3 rate of infection. They quarantined the infected again.

“If they hadn’t been identified, the infection would have resumed,” explained microbiologist Andrea Crisanti in the Guardian on March 20.

And now life appears to have resumed in Vo. For now.

The town of Vo is not alone in its aggressive tactics. Iceland has tested more of its 364,000 people proportionately than most other nations to date with the help of biotechnology firm deCode Genetics and has a much better understanding of its spread and how to contain it.

Avoiding the Diamond Princess mess

The Vo experience established a valuable principle, Crisanti argued: “testing of all citizens, whether or not they have symptoms, provides a way to control this pandemic.”

In this regard, the world has an excellent control study: the Diamond Princess.

The cruise ship contained 3,711 hapless travellers quarantined off the coast of Japan.

Authorities followed the recommended protocols: they only tested the crew and passengers with symptoms.

Meanwhile silent carriers with no symptoms spread the virus in close quarters.

Belatedly the authorities tested nearly 3,000 of the passengers. They identified 643 infections, an infection rate of about 18 per cent. The majority had no symptoms.

In Vo citizens battled an infection rate of three per cent down to zero with community testing combined with home quarantines.

Meanwhile the Diamond Princess watched an infection rate climb to 18 per cent with limited testing because most were silently infected prior to being confined to quarters.

The experience of Vo explains the fiasco of the Chinese outbreak in Wuhan several months ago.

The Chinese didn’t test the general population either. They acted late, and with a heavy hand.

When they ordered a lockdown, they sent carriers without symptoms into crowded homes. The key driver of the outbreak then became household transmission.

That forced the Chinese to track down the infected, house by house, condo by condo, dragging the infected from their homes to be isolated in stadiums and hotels.

Better for small places than big cities

Cristiani is the first to admit that Vo’s model won’t work in big cities where infection rates are high. A different battle plan is needed there.

But island and northern communities in British Columbia and other parts of Canada need a structured and nuanced approach.

What worked in Vo should work in most small communities.

So if you live on an island or a community the size of Vo get on the phone to local politicians and public authorities.

Organize. Direct politicians to prioritize diagnostic tests that can process results in hours and locally (they will soon be available).

Plan for local drive-in test centres. Test everyone. Isolate the infected. Lock your community down. Test and test again.

Canada is processing 10,000 tests a day and as the Globe and Mail’s veteran health reporter Andre Picard has also emphasized, that’s not enough.

But there are shortages of chemicals to perform the tests as well as PCR machines.

It may take a week or two to resolve these issues.

In the meantime communities can plan and get prepared. Mass testing combined with isolation and quarantines, and all exercised with community spirit, will keep death rates low; relieve hospitals; and prevent the infection from growing out of control in rural areas.

Finally, it gives communities a concrete plan, along with the hope of resuming life under altered conditions within weeks instead of months.

In the meantime, slow the viral spread and keep your community infection rate low with rigid physical distancing.

And then get to work with testing.