Why Portugal's Covid-19 test rate is more than double almost every other nation

Portugal is not a rich country. It doesn’t have Germany’s advanced pharmaceutical and manufacturing system, South Korea’s prior experience with Mers, Denmark and Switzerland’s money or the UK’s elite higher education system.

As the novel coronavirus ripped through Italy and neighbouring Spain there was genuine concern the Iberian nation with the fewest critical care beds in Europe would be next. So how does one of the eurozone’s poorer countries have a Covid-19 testing rate more than double almost every other nation in the world?

The answer is complex. But some of Portugal’s most respected medical experts say immense efforts from the private and university sector and a government that allowed them to act tell a big part of the story.

Beyond Latin linguistic roots, the scars of the European debt crisis, an appetite for fresh fish and an abundance of wine, Portugal shares many similarities with Italy and Spain.

It has the third-highest percentage of people over 65 after Japan and Italy, according to The World Bank Group, and grandparents are much more likely to live with their children and grandchildren than in the UK.

As authorities assured Britons the NHS was much better set up to deal with the pandemic than Italy’s regionalised health services, many Portuguese people were thinking the opposite.

Inês Fronteira is a professor of public health at the institute of hygiene and tropical medicine (IMHT) at NOVA University Lisbon and a former adviser to the Minister. She said news reports about what was happening in Spain and Italy motivated citizens to abide by social distancing restrictions very early on.

“I believe that there was some kind of – I wouldn’t say fear – but some kind of thinking that well we should be careful because we might not get the response that we need if we don’t stay home,” Professor Fronteira said.

“So if we don’t respect the isolation measures then we can end up in the hospital and we might not have the resources because other countries that are richer than us are showing that they are not able to respond to this.”

At last count in 2012, the 10 million-strong nation had 4.2 intensive care beds per 100,000 people, the fewest in Europe by some distance.

The story of Portugal’s success in fighting back the virus is relatively well known by now. SARS-CoV-2 arrived on March 2, almost a month after it hit Italy and Spain, and the government made the most of the reprieve. Portugal closed schools on March 16 with 331 cases confirmed and declared a state of emergency on the 19th with 785 cases, just five days after Spain did the same with more than 6,000.

Additionally, the health system is centralised like in the UK, not split into regions likely to move at different speeds, and the opposition decided very early on to support the government’s control efforts.

But none of that answers the question of how Portugal is managing to test more of its population than almost every country in the world.

While in the UK the NHS kept tight control of testing until recently, the Portuguese government quickly realised spreading the load was the answer.

As recently as May 1 to 17, non-state labs were still responsible for more than half of the almost 14,000 tests being conducted daily.

But the roots of Portugal’s world-class Covid-19 testing regime began much earlier. According to Our World in Data – whose testing rates have been cited by the OECD and others – Portugal has been among the top 10 countries in the world for testing per capita since mid-April.

On Friday, Denmark (with a GDP per capita 2.7 times that of Portugal) and Lithuania (with a similar GDP per capita to Portugal) were the only nations of more than 2 million people with a higher testing rate.

Like most countries, Portugal’s initial testing efforts started slowly amid difficulties securing kits in a ferocious global market.

“The stress initially was to provide testing,” said biology professor Miguel Viveiros, deputy director of IMHT.

“We were not prepared for testing in quantity for the speed of transmission.” In early March, Portugal was testing less per capita than the UK and much of Europe.

Professor Maria Manuel Mota, director of the institute of molecular medicine at the University of Lisbon, was speaking to doctors at the large university hospital on campus. They were worried about having enough tests to make sure the disease wasn’t spreading rapidly in the medical community, let alone for the wider population.

“Obviously there will be no testing for everyone,” they told her. “It is a difficult test, it takes a few hours, you know, it's expensive.”

Sitting at home on March 11, Professor Mota quickly discovered that didn’t have to be the case, thanks to her institute’s experience with PCR-based tests for malaria.

“The test we do all the time in almost every single lab in our institute is PCR, so it should not be difficult,” she remembered thinking. “Instead of relying on expensive kits that come from abroad … we could design something.”

To lead the project, she called on researcher Vanessa Zuzarte Luís, who had a potential testing protocol in mind within a few hours. The next day they were speaking to a Portuguese company about manufacturing the reagents needed for the tests, one factor UK authorities blamed for testing difficulties.

They were ready and working within a week, leaving only accreditation from the Dr Ricardo Jorge National Institute of Health left to secure.

“The Portuguese authorities were fantastic,” Professor Mota said. “As soon as I called the right people … they told us okay, let's validate this together.” The accreditation process ran smoothly and the tests were being rolled out to nursing homes by the end of March.

Within two or three weeks, university labs and private institutes across Portugal were using the protocol developed at IMM, or developing their own, to bolster public testing efforts.

In the UK, independent labs trying to take similar steps were still complaining their offers to help were being ignored as late as April 10, well after health secretary Matt Hancock set a target of 100,000 tests a day.

Meanwhile, from April 1 to 11, Portugal was conducting almost 9,000 tests a day. It doesn’t sound like a lot until you consider that England – with 5.5 times the population and 10 or more times the GDP – only managed 10,650 tests on March 31 and was aiming for 25,000 by mid-April.

However, even in Portugal, the picture is not all rosy. Almost 1,289 people have died, fewer than many European countries but many more than Austria, Denmark, the Czech Republic and Greece to name a few. Professor Viveiros hailed the decision to use the national health hotline to keep 85 per cent of patients out of hospitals unless absolutely necessary.

But in the early days the lines were badly overloaded and few patients were sent for testing unless they’d had contact with a confirmed case. A survey by the Order of Doctors released on May 18 revealed not even half (47.17 per cent) of the 2,353 Portuguese doctors who had contact with cases, suspected cases or symptoms of Covid-19 had been tested.

Now, as the country reopens in stages, antibody testing is entering the equation. The Portuguese authorities have proceeded much more cautiously on this front, avoiding language such as “game changer” used by Prime Minister Boris Johnson and waiting for antibody tests guaranteed to work.

That means the first national serological study has only been running since the middle of this month, after the lockdown was lifted and IMM is still working on a large-scale solution.

Doctors, experts and authorities alike stress the effort to control the pandemic isn’t over. A Portuguese population so willing to go into confinement to save the national health system must feel comfortable to return to the streets and restart the tanking economy, while knowing things can’t return to normal any time soon.

Filipe Froes, one of the country’s most respected pulmonologists, said the anti-Covid effort  had hinged not just on the rapid government response but on the wider community. From the citizens who stayed home or made PPE for doctors, to the winemakers who started making disinfectant and the factories churning out masks and face shields.

“In the end, this is not a miracle. This is work and organisation,” Dr Froes said. “We follow a strategy. In Portuguese, we say this: ‘If you don’t know where to go, no wind is favourable.’ “So we knew where to go and we took advantage of the two weeks ahead of us to prepare.”

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