On July 10, the Ministry of Health created the Commission for Evaluating and Following the Plan of Expansion of National Laboratory Capacity (https://dre.pt/web/guest/home/-/dre/137602111/details/2/maximized?serie=II&parte_filter=31&day=2020-07-10&date=2020-07-01&dreId=137571473). Acknowledging the crucial role of laboratory diagnosis of SARS-CoV-2, the Ministry of Health aims to further expand lab capacity within the NHS. The Commission must undertake an assessment of the current network of laboratories and present a plan for expanding the laboratory capacity, conducting a cost-benefit analysis, and considering both investments in the current infrastructure and creation of new labs.
The results of the expansion of testing capacity were already observed in September 2020: during that month, the NHS performed an average of 8,750 daily tests (compared to an average of 5,603 daily tests in June 2020). Overall, Portugal performed an average of 18,867 daily tests in September (compared to an average of 11,830 daily tests in June).
Between March 2 2020 and January 24 2021, Portugal performed 6,903,380 tests for diagnosis of SARS-CoV-2 in public and private laboratories, including 347,434 rapid antigen tests, which places the country in 6th place among the EU countries regarding testing rate, with 678,142 tests per million population (https://covid19.min-saude.pt/ponto-de-situacao-atual-em-portugal/). Portugal performed an average of 43,549 daily tests, between January 1 and 24.
The National Testing Strategy for SARS-CoV-2 was published on October 26 (https://www.dgs.pt/normas-orientacoes-e-informacoes/normas-e-circulares-normativas/norma-n-0192020-de-26102020-pdf.aspx). Molecular tests remain the first option for COVID-19 diagnosis, while rapid antigen tests should be used if a molecular test is not available or if the result will take longer than 12 hours in the following situations:
- Patients without criteria for hospitalization, isolating at home;
- Patients with criteria for hospitalization, with additional testing for influenza A and B, and also for sincitial respiratory virus in children under the age of 2 years;
- Diagnosis of COVID-19 in asymptomatic persons with close contact with a confirmed case;
- Healthcare units, before admission of patients or procedures generating aerosols;
- Institutions for vulnerable populations, including nursing homes and shelters for refugees and migrants.
For cancer patients, molecular test remains the only option.
Rapid antigen tests can also be used, as first option, in situation of outbreaks and also periodic testing (7 to 14 day) of healthcare workers highly exposed to the infection.
Following the peak of the third wave by the end of January, the number of tests in Portugal declined due to less suspected cases and less high risk contacts to be tested. In order to prepare an adequate level of testing prior to the lifting of lockdown measures, the National Testing Strategy for SARS-CoV-2 was updated on 26 February (https://covid19.min-saude.pt/wp-content/uploads/2021/03/Norma_019_2020_act_26_02_2021.pdf). The updated version established:
• Testing all contacts irrespective of their high or low risk exposure
• Screening in educational settings
• Screening in high-risk work settings
• The possible use of saliva as sample for PCR tests.
As a result, 82.425 tests (rapid antigen testing) were carried out between 16-21 March to personnel of schools and nurseries (81 positives identified).
Between 2 March 2020 and 28 March 2021, Portugal performed more than 9 million tests for diagnosis of SARS-CoV-2 in public and private laboratories, including around 800,000 rapid antigen tests. Portugal performed an average of 28,500 daily tests/day in March 2021.
The current testing policy in Portugal includes testing for all suspected cases of infection by SARS-CoV-2 (https://www.dgs.pt/directrizes-da-dgs/orientacoes-e-circulares-informativas/orientacao-n-0152020-de-23032020-pdf.aspx). Testing can be carried out in a hospital lab, a private lab or in the National Institute of Health Dr Ricardo Jorge, which is the national reference laboratory in Portugal. Laboratory testing of SARS-CoV-2 is done by real-time PCR (RT-PCR), as recommended by WHO.
Initially, suspected cases had a very strict pathway for referral: they had to call SNS 24 Contact Centre, be validated by the Medical Support Line, and be sent to a reference hospital for sample collection and testing. Also, the National Institute of Health was the only laboratory performing tests for SARS-CoV-2. However, even before the first confirmed cases in Portugal were identified, a network of hospital labs was established, making it possible to be tested at the reference hospital. As the epidemic evolved, and although the SNS 24 Contact Centre is still the preferable way of entering the pathway of identification of cases, other options are available. Home testing is possible for mild cases that do not fulfil criteria for hospitalization. Additionally, many testing centres (especially, drive-throughs) are being set up in several Portuguese cities, improving access to testing, as long as the person holds a medical prescription. Hence, not only suspected cases but also close contacts and even asymptomatic persons have been tested for COVID-19.
Testing capacity has been strongly increased across the country as more hospital labs became prepared to perform testing and private labs were included as part of the national response. Currently, the National Institute of Health, the Military Laboratory, the National Institute for Agriculture and Veterinary Research, 37 labs in public hospitals (including the autonomous regions of Azores and Madeira), 22 university labs and 27 private groups (with more than 100 posts across the country) are performing SARS-CoV-2 diagnosis. Monitoring and surveillance of cases (and deaths) include long-term care facilities and/or home care.
Results usually take 5-6 hours to be delivered, depending on the hour the samples are delivered in the lab and the number of swabs to be processed. However, 5,000 PCR testing kits became available in mid-April, which deliver results in around 45 minutes. Those are reserved to particular situations, including testing suspected cases in health care settings or pregnant women.
The results of the expansion of testing capacity were already observed in October 2020: during that month alone, the country performed 804,095 tests for SARS-COV-2 diagnosis.
Between March 2 and October 31, Portugal performed 3,429,541 tests for diagnosis of SARS-CoV-2 in public and private laboratories, which places the country in 8th place among the EU countries regarding testing rate, with 330,198 tests per million population (https://covid19.min-saude.pt/ponto-de-situacao-atual-em-portugal/).