Iceland has tested more of its population for coronavirus than anywhere else. Here’s what it learned

By Friday, Iceland will have achieved something no other country has: tested 10% of its population for coronavirus, a figure far higher than anywhere else in the world. 

No country or scientist or doctor has all the answers about the pandemic that has swept the globe, infecting more than 1.6 million people and killing at least 95,000. 

But some places, such as tiny Iceland, Europe’s most sparsely populated country – pop. 364,134, broadly equivalent to the number of people in Tulsa, Oklahoma – may be better placed to deliver some types of coronavirus information, and even answers, than most, at least in the short term, according to public health experts, international government officials and others involved in responding to the outbreak. 

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“The size of a place matters. It tracks with the number of introductions of the virus. It is no coincidence the places now doing (the best work) share this feature,” said William Hanage, an epidemiologist at Harvard University’s T.N. Chan School of Public Health. 

To be clear, Iceland has not yet been able to provide definitive explanations for the most pressing coronavirus questions vexing scientists, politicians and publics the world over. Among them: its transmissibility; why it hits some people exceptionally hard and affects others only mildly; the most promising vaccines and treatments; actual mortality rates; and whether lifting lockdowns will later usher in a deadly second and third wave of new infections – if the so-called coronavirus curve, in fact, looks more like a loop. 

Hanage said in terms of lasting analysis models for our understanding of the virus it’s also not clear for how long size will matter to health experts probing the disease.

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Still, for now, Iceland may be one of best live coronavirus laboratories we have, according to Kari Stefansson, an Icelandic neurologist and chief executive officer of Reykjavik-based biopharmaceutical company deCODE genetics, which has partnered with Iceland’s government to carry out its massing testing efforts. 

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Among the Nordic nation’s findings: about half of its citizenry at any given time who have coronavirus but don’t know it, will be asymptomatic – a large percentage many experts studying the virus have suspected, but have had little firm data to corroborate. 

“That’s a bit scary,” said Stefansson, who noted that Iceland is testing its citizens at random by selecting names out of the country’s main telephone directory, another large-scale testing strategy that has not been adopted elsewhere.

“They could be spreading it and not knowing it,” he said.

‘It means the containment efforts of the authorities are working’

Iceland has not imposed a full national lockdown.

Its restrictions are largely based on trust. Most shops and businesses are still open.

However, the country has banned gatherings of more than 20 people. Of Iceland’s more than 1,600 coronavirus infections as of April 10, six have ended in deaths. 

Like other localities such as Taiwan, Singapore and Hong Kong that have moderately sized populations and relatively diminutive geographies, Iceland has proved successful at “flattening the curve” – keeping the number of coronavirus infections at a manageable level for medical workers who would otherwise be overwhelmed with sick patients.

In Iceland’s case, it has done this through a combination of rigorous testing and tracing. Authorities say Icelanders are heeding social distancing recommendations.

Stefansson said Iceland’s randomized tests revealed that between 0.3%-0.8% of Iceland’s population is infected with the respiratory illness, that about 50% of those who test positive for the virus are asymptomatic when they are tested, and that since mid-March the frequency of the virus among Iceland’s general population who are not at the greatest risk – those who do not have underlying health conditions or signs and symptoms of COVID-19 – has either stayed stable or been decreasing.

This data has yielded, he said, yet more knowledge.

“It means the containment efforts of the authorities are working,” he said. 

A police officer wearing a face mask stands guard at Tianhe Airport after it was reopened on April, 8, 2020, in Wuhan in China's central Hubei province.

While many countries publish daily and cumulative infection and death rates, there don’t appear to be comparable statistics for other nations available that give an overall sense of how deep-rooted the virus is, or how many carriers of the disease, at any given time, may have no symptoms. Iceland has not yet been able to determine how many asymptomatic infections, once confirmed, will later go on to develop symptoms.

John P.A. Ioannidis, a professor biomedical data science and epidemiology at Stanford University, said that the “best data” on coronavirus is currently coming from Iceland. But that may be partly because Iceland is the only country that has so much data, even if it’s too early to draw unequivocal conclusions about what the data are saying. 

President Donald Trump said on April 6 in a press briefing that almost two million Americans have been tested – 0.6% of the population – but it’s not clear what metrics the White House is relying on and hundreds of hospitals have complained about severe shortages of testing supplies and long waiting times, according to a report from the Inspector General for the Department of Health and Human Services. Although access to testing in the U.S. does appear to be improving in some areas. 

According to Worldometer, an online statistics website run by an international team of developers and researchers that collates public health information published directly by each state, the U.S. has conducted about 2.3 million coronavirus tests. That equates to about 7,100 tests per one million people. Using that same scale that accounts for Iceland’s six-figure population, Iceland has undertaken 96,000 tests per million people.   

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Some countries, such as Germany, have predicted that up to 70% of their nationals could eventually contract coronavirus. And officials at the U.S. Centers for Disease Control and Prevention have said that under a worst-case scenario, between 160 million and 214 million people in the U.S. – 48% to 64% of Americans – could be become infected over the course of the epidemic, although those numbers don’t account for various social-distancing measures underway aimed at slowing transmission rates. 

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Gestur Palmason, a police detective deployed as a coronavirus “contact tracer” at Iceland’s National Crisis Coordination, said few other places would have the resources or serendipitous combination of factors to carry out Iceland’s preliminary research. 

These include the island-nation’s remoteness, the high regard its nationals have for scientific expertise – medical experts, not politicians, are leading its response – its tech-savvy government infrastructure, a relatively tried and tested emergency agency that is used to dealing with volcano eruptions and avalanches, and yes, fewer people. 

“Scale is important but also for reasons you might not initially think,” Palmason said.

“The smaller the population you have the more chance there is you will know someone who is affected. Whatever your government or law enforcement may be saying, you are much more likely to want to play a part and take recommendations seriously because of that personal connection – compared to places where there are tens of millions of people and you may not have been to parts of the country or know people there.”

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Still, Wang Ting-yu, a Taiwanese lawmaker who has been active in the East Asia island-state’s much-admired response to its coronavirus outbreak, said that while he was watching Iceland’s experiment with mass testing and data with interest – noting that Taiwan has also rolled out islandwide coronavirus screening – he thought that other western countries in Europe and North America would be better off at this stage of their fight with the disease by adopting a “war time” mentality to combat the outbreak.

This means, Wang said, strictly enforced quarantines, protecting frontline workers with the most advanced personal protective equipment and a whole-of-government approach to keeping the public informed about lockdowns, setbacks, any changes in tactics and, crucially, developing tailored technology to deliver this information.

Taiwan has a similar population to Australia – about 24 million people. Both are islands, although Taiwan’s population density is far higher. As of April 10, Australia has recorded more than 6,100 coronavirus cases and 53 deaths. Taiwan has 382 cases and 6 deaths.

In New Zealand, another small island-nation – pop. 4.7 million – that early on in the global pandemic imposed a tight lockdown strategy aimed at totally eliminating the virus rather than just containing it, there has been just 2 deaths amid more than 1,200 cases.

“Our message to our friends abroad is: centralize your response,” Wang said. “If you don’t move quickly, or with enough purpose, then the price is peoples’ lives.” 

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‘We now seem to be the safest place on the planet’

Governments from Rome to Berlin have indicated that daily new coronavirus infections and death tolls may be on the verge or even already be starting to plateau or fall as a result of social distancing measures. The White House has made similar claims.

New York state has actively flattened its curve with social distancing regulations, Governor Andrew Cuomo said in a press briefing on Wednesday. 

Singapore, Hong Kong and even China, where coronavirus originated in December last year and authorities have all but claimed total victory over COVID-19, have meanwhile seen rising clusters of new infections in recent weeks. While most of these cases are imported, it remains unclear whether by lifting restrictions authorities around the world will be forced into a game of coronavirus whackamole with no obvious end date. In the last few days Japan, which initially held off on a lockdown, has fortified its restrictions.

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The U.S. has largely relied on a patchwork of social distancing measures and lockdowns dictated at state level, while the Trump administration has offered federal guidance that is not mandatory to follow. More than 468,000 people in the U.S. have been infected with coronavirus and the number of deaths – over 16,600 – appears on track to soon match or surpass Italy, where the most people – more than 18,000 – have died.  

Still, in terms of collecting actionable data about coronavirus, Hange, the Harvard epidemiologist, questioned whether Iceland would be better off focusing on serological tests that could determine whether a person had developed certain antibodies in the blood indicating that they were infected by the virus without knowing it, and recovered.

Knowing whether these antibodies exist in someone’s blood could, potentially, enable tens of millions of people around the world to reenter the workforce at a time economies are reeling because they are under orders to stay home to prevent the virus’ spread.

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“Random testing for ongoing infections helps but runs into a lot of issues,” Hanage said.

“If you find someone is positive and asymptomatic now, you still have to wait until they have recovered to know the course of their illness,” he added, noting that some reports out of Italy indicate that the most seriously affected towns in the nation’s Lombardy region show a large portion of the population with signs of immunity.

“If true this is obviously a very good sign, but it has come at an appalling cost,” he said. 

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The U.S. Centers for Disease Control and Prevention has begun preliminary studies into serological tests – called sero-surveys – to try to determine what proportion of Americans caught the disease but evaded detection. No results have been published.

Various U.S. cities are launching their own antibody studies. 

Stefansson, the CEO of deCODE genetics, which is doing Iceland’s testing in coordination with the government, said it started screening for antibodies on April 8.

Germany has started Europe’s first large-scale coronavirus antibody testing effort to help researchers assess infection rates more effectively.

Still, one place where the coronavirus data are especially pure, and small, is Antarctica. 

While more than 100 people from Australia, Europe and the U.S. on board a cruise ship traveling to Antarctica and South Georgia tested positive this week for coronavirus, the ice-covered landmass is the only continent that remains untouched by the outbreak. 

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“We now seem to be the ‘safest’ place on the planet,” said Stijn Tholen, a European Space Agency medical research doctor who is spending a year on the ice investigating how humans adapt to living in extreme environments, in an email. 

“The increasing darkness and cold here already feel so otherworldly, and to see what is happening in the rest of the world makes me feel even more distant,” he said. 

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