Germany’s ‘bottom-up’ testing keeps Covid-19 at bay

“It is much more expensive to test too little, than to test too much”.

That is the mantra Germany’s health minister, Jens Spahn, has repeated for months as the country mobilised a vast network of private and public laboratories to quadruple its early Covid-19 testing capacity to almost 1.6m tests per week.

Such early interventions helped the EU’s most populous state tame the coronavirus pandemic more successfully than most of its neighbours. Germany’s 361,000 infections represent just a fraction of the 4.5m in Europe so far, significantly lower than the 936,000 cases in Spain and the 708,000 cases in the UK, both of which have much smaller populations.

As of last week, Germany had processed more than 19m polymerase chain reaction (PCR) tests and is consistently handling more than 1.1m samples a week. That is a fewer tests per capita than the UK — 1.5m tests a week — and a similar to level Spain — 700,000 tests a week. But until now Germany’s testing system has largely avoided the bottlenecks and regional supply shortages that have hobbled testing elsewhere.

“The special situation in Germany is that we historically have a network of private labs, spread out nationwide, which are more or less connected and work together cooperatively,” said Michael Müller, the chairman of ALM, which represents 109 laboratories doing the bulk of the country’s testing. “We didn’t have to invent anything new.”

Germany has tested fewer people for Covid-19 than the UK but its system has functioned much better © Thomas Kienzle/AFP via Getty

Roughly 90 per cent of testing in the country is done by self-governing private laboratories. That means Germany has consistently had excess capacity of around half a million tests a week, leaving the system well placed to deal with sudden spikes in demand. One outbreak in the Tönnies meat processing plants in North Rhine-Westphalia in June created a need for 50,000 extra weekly tests as the disease was traced in local communities.

This contrasts with the UK’s system, which was heavily centralised from the start. The government overlooked existing labs in favour of creating five so-called “lighthouse laboratories” — outsourced, purpose-built facilities tasked with processing tens of thousands of tests a day. The sites quickly faced setbacks and have become overwhelmed at several points during the pandemic, creating bottlenecks and delays. NHS England eventually wrote to all its labs across the country in August asking if they could provide additional capacity.

Line chart of Tests per 100,000 people showing Germany carries out fewer tests than UK

Christoph Mahnke, chief executive of Germany’s Synlab, a private-equity owned diagnostics business that now handles 200,000 tests a week, said the expansion of testing in Germany had been “a bottom-up process” that gathered speed once the government said it would fund all necessary tests. “There was never a question that labs would be paid,” he said. “That gave us the assurance to invest”.

With the funding in place, private laboratories co-ordinated with a pre-existing network of 400 local health authorities, which had been doing contact-tracing for years. Underfunded and understaffed, the local agencies had historically traced measles outbreaks and measured water quality. They were strengthened in response to the pandemic and, together with the laboratory and hospital network, were able to track and test infections without waiting for precise directions from the German federal government.

Although they are independently run, the ALM network of laboratories have adhered to a tiering system developed by the Robert Koch Institute (RKI) — Germany’s public health agency — and the health ministry, to assess who to test first.

Under the guidelines, in place since the start of the pandemic, symptomatic patients must be tested first followed by those who may have come into contact with a confirmed Covid-19 case and, finally, people in hospitals and care facilities.

Private laboratories have co-ordinated with a pre-existing network of 400 local health authorities previously used to trace outbreaks of diseases such as measles © Sean Gallup/Getty

Germany also has an effective gatekeeper system. While paid-for private tests are widely available at airports and online, those wanting to be tested under their insurance must go through a doctor, who decides whether a test is necessary. 

This has led to consistent excess capacity in many parts of the country. It allowed Bavaria — Germany’s wealthiest state — to offer free tests to all who wanted them this summer and for the government to fund tests for all those arriving into the country until mid-September.

By contrast, in the UK, access to testing is not mediated by any public health body. Official guidance now dictates that only those showing symptoms should get tested but in practice anyone can go online and request a test, whether they are symptomatic or not.

Some of Germany’s largest employers have also relieved public facilities of the strain. Deutsche Post, which has roughly 220,000 staff in Germany, said it had conducted nearly 6,000 tests largely using its own medical facilities, while Volkswagen has processed more than 3,000 tests since opening its own lab in August, using just a tiny fraction of its on-site capacity.

The German system now faces its biggest test since the early weeks of the pandemic, with the number of new daily cases in the country reaching levels last seen in April, and the onset of the flu season expected to put greater strain on testing capacity.

New quarantine requirements for those travelling from so-called “risk regions” within Germany, which can in some cases be circumvented via a negative test, have increased demand And the RKI has warned the necessary maintenance of diagnostics machines could slow down processing times, and that bottlenecks could disrupt the imported supply of reagents, as other countries increase their testing too.

But Mr Spahn has said the German government will continue to adopt a laissez-faire approach to expanding testing capacity. “Our experience is that the moment the state interferes in these supply chains, it is more of a hindrance than a help,” he said this month.

Additional reporting Daniel Dombey in Madrid

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