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Coronavirus testing gaps put Asian governments under microscope

Fear of overwhelming health systems prevents wider screening outside South Korea

One of South Korea's drive-thru testing centers: Asian countries have taken dramatically different approaches to screening for the coronavirus.   © Reuters

TOKYO -- After a slow start, Japan has stepped up its response to the new coronavirus over the past two weeks. But health officials are still being asked the same question at their weekly briefings: Why is South Korea testing more people?

The Northeast Asian neighbors are not the only ones with a big gap in testing rates. Across the region and around the globe, authorities have adopted a range of strategies for screening their populations. There are myriad factors involved: experience with epidemics, health care resources, types of tests available, bureaucratic bottlenecks and government guidance.

Individuals who suspect they might be infected are in for a dramatically different experience, depending on where they reside. South Korea offers drive-thru testing. Japan insists that individuals phone into a call center first. Thailand has set up an online self-assessment form.

The gulf between South Korea and Japan has drawn particularly close scrutiny because of the countries' similarities.

Japan has well over twice the population. But the two nations have comparable gross domestic product per capita. Both receive millions of travelers from China each year. And both have universal health care.

Yet, South Korea has checked over 210,000 individuals for the virus and has raised its daily testing capacity to 15,000, while Japan has lagged behind at 6,000 tests per day and a total of over 21,000 checks since mid-February.

South Korea's more aggressive testing had detected 7,869 cases as of Thursday. That number looks frighteningly high compared with Japan's 622 -- excluding the outbreak-stricken Diamond Princess cruise ship that docked at Yokohama -- but it is equivalent to about 4% of all tests. Meanwhile, Japan is dogged by concerns about how many cases are going undetected.

"What South Korea does show is that it is possible, technically, to rapidly develop and scale testing," said Scott Burris, director of the Center for Public Health Law Research at Temple University.

South Korea learned from its experience with MERS, which killed 36 people and infected 186 in 2015. Testing centers for infectious diseases were set up outside of public hospitals, where the waiting rooms could be hotbeds for infections. The country was also quick to give doctors the power to order coronavirus tests, enabling the testing centers to set up drive-thrus where people are swabbed without leaving their cars -- lowering the risk of cross-infection.

"If doctors suspect a COVID-19 case, they can proceed with testing without restriction," an official from the Korea Centers for Disease Control and Prevention said at a coronavirus briefing on Monday.

Not everyone who goes to the drive-thrus gets tested. Staff assess each individual's risk based on World Health Organization criteria and test accordingly. Still, health authorities encourage anyone concerned about infection to come for an assessment. Those who are tested are informed of their results in three to four days.

Japan uses the same WHO criteria, but apparently with a stricter interpretation. Telephone screening present an additional roadblock.

Before getting checked, one must phone a call center run by the health ministry, which filters out possible cases. The general guidance is to consider requesting a test through the call center only if symptoms persist for four days or more, or two days for the elderly.

The ministry said the call center prevents overloading the health care system -- a worry shared by other countries fighting the pandemic.

"I don't think there's any country that is offering tests to all who request them," said Dr. Yasuyuki Sahara of the ministry's global health division. "Some contact history or travel history or pneumonia are the conditions that have to apply before you perform the test."

Individuals who were exposed to passengers from the outbreak-stricken Diamond Princess cruise ship told Nikkei they developed cold and flu symptoms but were advised by the call center to stay home instead of going in for tests.

Still, Sahara insisted the country has the capacity to test everyone who fits the criteria. "As of now, more PCR test capacity is secured than the actual number of conducted tests," he said, referring to the polymerase chain reaction tests used to identify coronavirus cases.

No country has deployed wholesale testing on South Korea's level.

A worker at Bangkok's Suvarnabhumi Airport: Thailand asks individuals to fill out an online coronavirus self-assessment form but leaves it to them to decide whether to proceed to a hospital for testing.   © Reuters

In Taiwan, where President Tsai Ing-wen has received the highest approval ratings of her tenure for her response to the virus, only those who had close contact with confirmed patients qualify for testing.

But Taiwan mounted one of the fastest responses to the outbreak, aided by an amendment to the Communicable Disease Control Act last June that expanded the government's powers in an epidemic. Even before that, Taiwan learned from the SARS outbreak and established in 2004 a National Health Command Center, which was activated by the Taiwan Centers for Disease Control back on Jan. 20.

"Early recognition of the crisis had allowed Taiwan to prepare for the necessary tests for COVID-19 as it happens, and scale its capacity over time," said Dr. C. Jason Wang, director of the Center for Policy, Outcomes and Prevention at Stanford University.

Over in Thailand, the Ministry of Public Health encourages individuals to fill out an online self-assessment form but leaves it up to them to decide whether to proceed to one of eight state hospitals. Unlike South Korea and Japan, where public health insurance covers the tests, Thais face a 15,000 baht ($474) bill.

In the Philippines, despite a lack of universal health coverage, the government is shouldering the cost of testing and has found 49 cases as of Thursday. But the country has just 4,550 tests on hand for a population of over 109 million.

The Philippines does appear to have a path to expand that capacity, however. On Tuesday, the day after President Rodrigo Duterte declared a state of emergency, the Food and Drug Administration allowed a kit locally developed by the University of the Philippines and National Institutes of Health to be used to test for SARS-CoV-2, the virus that causes COVID-19. The new kit would allow more testing without waiting for WHO supplies.

Other countries may not be so quick to embrace new tests.

Commuters in Manila on March 11: The Philippines has detected a relatively small number of virus cases but has declared a state of emergency.    © Reuters

Riken, Japan's public research institute, and precision equipment maker Shimadzu are developing tests that would work in 30 to 60 minutes -- versus the two hours and 15 minutes it currently takes Japanese labs to check for the virus. But even once these kits are ready, there is no mechanism for fast-tracking approval from the Pharmaceuticals and Medical Devices Agency. And health officials have indicated that they would prefer to rely on the WHO tests already in use.

"We have concerns about the [tests] that give rapid results," said Dr. Takuma Kato, director of the health ministry's influenza control office. "Generally, when it's fast, sensitivity tends to decrease, so to what extent will the lower sensitivity be practical?"

In the U.S., which has also faced criticism over limited testing, the Centers for Disease Control and Prevention developed a test that takes just 45 minutes and distributed it to 48 state laboratories. But there was a snag -- a production error left the CDC as the only lab able to run diagnostics.

The U.S. Food and Drug Administration has fast-track authority that would allow state and local labs to develop their own tests based on CDC guidance, but has not activated it.

As things stand, the U.S. has checked far fewer people than Japan, and patients have to pay as much as $3,200 out of pocket to be tested. Waiving the fee is a state-level decision -- one that New York State and Massachusetts have made.

Few would disagree that test data is critical for grasping the scope of the outbreak, the fatality rate and how fast the disease spreads. But coronavirus-hit countries may never agree on the best way to collect that data.

Additional reporting by Cheng Ting-Fang and Cliff Venzon. 

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