Coronavirus: Iceland offers covid-19 testing to the entire population, best strategy

In the nearly polar north, Iceland, an island dotted with fjords and lit by northern lights, shows a peculiar approach to fighting the coronavirus.

Iceland's strategy in tackling coronavirus is unique from other countries way of fighting Covid-19. In the nearly polar north, Iceland, an island dotted with fjords and lit by northern lights, shows a peculiar approach to fighting the coronavirus.
Coronavirus: Iceland's ‘world's only’ strategy, the country that offers covid-19 testing to the entire population
While the number of deaths and infections multiplies every day in its neighboring countries and in almost the entire planet, the Nordic nation has managed to keep covid-19 at least at bay: in almost two months it has only reported four deaths and about 1,500 cases.
And for this, it has not needed to enact quarantines or mandatory confinements: although meetings of more than 20 people have been suspended, many stores and businesses are still open and children at some levels of education continue to go to schools.
‘It is the result of a strategy that I consider very successful and that I think is unique in the world as far as my knowledge goes,’ Icelandic epidemiologist Kristjana Asbjornsdottir, a professor at the University of Washington in the United States, said.
The starting point of the Icelandic approach has followed one of the basic recommendations of the World Health Organization (WHO) since the coronavirus began to spread everywhere: do ‘tests, tests and more tests’ and, from that, make the decisions.
But unlike other nations, in Iceland not only suspected cases, potential infections or people at risk are tested: the country offers the coronavirus test to anyone who wants to do it and for free.
‘The primary strategy in Iceland has been based on extensive testing, not only of high-risk or symptomatic individuals, but also of the general population,’ Jóhanna Jakobsdóttir, professor of biostatistics at the Center for Sciences, explains to the World Public Health from the University of Iceland and part of the covid-19 response team in the country.
But free, mass testing has not been the only approach that has enabled Iceland to offer a particular response to the coronavirus: innovative measures to locate and isolate new infections have also been part of the strategy.

A novel vision

When Iceland detected its first case of covid-19 last February, it had been testing for the virus for weeks on tourists or people returning from a trip to the country.
According to experts consulted, this ‘vigilant’ approach of trying to attack the disease even before it appeared in the community was a decisive step.
‘I think we were the only country in the world that had been testing for a long time before the first case appeared,’ Kari Stefansson, director of DeCode Genetics, the biotech company that is leading efforts to conduct massive coronavirus tests together, said to the Ministry of Health.
Unlike what happened in other countries, where people already went to hospitals ill, in Iceland the authorities asked those who entered the island to report to health centers to have tests even if they did not have symptoms.
But in mid-March, as the cases increased, DeCode Genetics decided to open the spectrum and not only test potential infections or people with symptoms or a history of travel to risk areas: whoever wanted to could get a coronavirus exam.
‘We did this because we understood that it was necessary to know how fast the virus was spreading through the population and to be able to design methods to contain the disease,’ says Stefansson.
Initially, the sampling was voluntary, but since last week the company even started calling randomly from Icelandic phone book numbers to invite the respondent to come to its branches for a test.
And while this is possible largely because of the country's demographic characteristics - Iceland's population is around 360,000 - experts believe that the scope of this approach may be useful to nations with larger populations.
‘Iceland has a very small population, but I think the results of this approach can clarify many of the scientific questions we have about the true extent of the virus,’ says Asbjornsdottir.

Other strategies

According to Jakobsdóttir, the massive testing of the population has been the basis for the rest of the strategies and political decisions that the country has taken to contain the spread of the virus.
Once the cases are identified, he says, the authorities proceed with a rigorous follow-up of the contacts of the infected people, who are placed in confinement regardless of their state of health.
‘Currently, about 50% of new cases is already in quarantine at the time of diagnosis, ’ he says.

Iceland has based its strategy on mass testing of its population.

Another element, in his opinion, was that the authorities decided to isolate the populations at risk from the detection of the first infections.
‘Nursing homes and hospitals have been closed to visitors since the first case, so Iceland has been able to protect better than many other countries at higher risk of serious complications,’ he says.
According to government figures, Iceland only has 20 intensive care beds with respirators to treat potential cases of covid-19, hence the urgency to avoid an increase in infections.
To detect new infections, the Icelandic authorities have used ‘police’ strategies that have already been implemented by other Asian countries, such as Singapore: using detectives and criminal investigation agents to locate potential new cases.
‘That is another important element: Public authorities have been very effective in tracking potential cases and encourage everyone who has had contact with sick people to quarantine even before symptoms appear,’ says Asbjornsdottir.

Iceland has not decreed quarantines or confinements like other countries in Europe.

Stefansson agrees that this strategy has also been decisive given that almost half of the cases that have been positive in the examinations that his laboratory has carried out showed no symptoms at the time of the test (although many developed them later).
‘Examining the general population and those who are asymptomatic provides a more accurate picture of how widespread the virus is in Icelandic society and how it is moving,’ he says.
For weeks, medical authorities in several countries have warned of the role of asymptomatic patients in the transmission of covid-19, and that the coronavirus spreads even before the first symptoms appear.

The importance of testing

Until Monday, Iceland had carried out the coronavirus test on 6% of its inhabitants, the highest examination rate in the world by population, according to WHO data.
To give you an idea, until last Friday (latest available data) the US, although with a quantitatively higher number of inhabitants, had only tested 0.4% of its population, most of which already had symptom.
While South Korea, the country that has made the most tests (almost half a million), had tested until this Monday to 0.7% of its inhabitants and continued to do so only to suspected cases or people in risky circumstances.

Iceland has tested 6% of its population.

‘By conducting large-scale population tests as in Iceland, you can have a better pattern of what the overall status of the infection is and how widespread the virus is in the community,’ says Asbjornsdottir.
‘If the tests are only available to those who are very serious, it is overestimating what is actually happening,’ he adds.
Stefansson agrees that, by better understanding the spread status of the virus in the population, it is easier to have reliable data on case fatality or morbidity rates (how contagious it is).
‘The data we have on the impact of the coronavirus in the world are unreliable because nobody has a real measure of the impact on its general population, given that only serious cases are tested,’ he believes.
‘So far, the only country in the world that could offer a true coronavirus case fatality rate number is Iceland,’ he says.

The sequence of the virus

The expert notes that another striking element in Iceland's response is that the virus has been sequenced in all cases that have tested positive for covid-19 in the country.
‘This has shown that since the coronavirus has been spreading so widely, it has had a large number of mutations, even though it has a low mutation rate compared to other viruses, for example the flu virus,’ he says.

The genetic sequence of each virus in positive cases is studied in Iceland.

Stefanson, who was a professor at Harvard University, says that the study of these variations in the viral genetic sequence can be used to trace the origin and spread of covid-19 to individual cases.
‘That helps when it comes to tracking the infection, when you want to find out how it moves through society. You can tell if people have been infected with the same individual by simply sequencing the virus and thereby placing it in context of how the mutation moves, ‘he argues.
According to the expert, to date, his laboratory has detected very specific mutations of the viruses that come from countries or areas of Austria, Italy, the United Kingdom, or the west coast of the United States.
And in that sense, he says one of the questions that remains is why some of these mutations turn out to be more aggressive than others - and mortals .

The teachings of Iceland

Jakobsdóttir believes that after three weeks of extensive testing, the Icelandic scientific community is optimistic that the strategy, at least for now, is working.
‘As of March 23, the number of cases seemed to be growing exponentially, but we have seen that we have strayed from that path and the increase now seems more linear,’ he says.
However, he believes it will still take some time until the number of infections starts to decrease.
However, he is optimistic that so far, the data suggests that the island ‘is on the right track without giving very prohibitive draconian responses.’

Iceland has developed a different strategy from the rest of the countries in Europe.

‘The strategies implemented in Iceland have been policy-free and science-driven. Politicians, on the other hand, have used their energy where they should, in designing and implementing economic and social policies for the inevitable effects of the pandemic.’
‘The most important message of Iceland's strategy is that decisions must be based on science.’

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