Paul Evans –

Mass testing of the community for Covid-19 is yet to be a priority in the UK, despite evidence from South Korea and China showing that it was vital in beating back the virus – so why aren’t we recruiting an army of public health volunteers to help make it possible?

The theory is that tracking down people who have newly acquired the virus before they have time to pass it on will help put a lid on transmission. It is a standard tool in the public health response to infectious disease and the UK deployed it at the start of the Covid-19 outbreak.

The World Health Organisation advice to governments is clear,  “isolating, testing and treating every suspected case and tracing every contact must be the backbone of the response in every country. it is the best hope of preventing widespread community transmission”

Once a pandemic was announced though, the UK government changed tack, switching the focus of testing resources on to hospital patients.

Two weeks weeks on and it’s still trying “to ramp up” testing for NHS patients and their families, as around 10-15% of health staff are reportedly away from work as they can’t be sure whether they have the virus or not. 

The government is aiming to carry out 100,000 tests a day in England by the end of April, but by April 6 daily testing had only reached around 14,000.

It remains unclear how much of the new target will be community-based, but Mr Hancock confirmed that the ultimate goal is to roll out mass community testing “as soon as possible”, so that “anyone who needs a test shall have one”.

 

What’s the exit strategy?

Labour’s new leader, Keir Starmer joined others in calling for the government to reveal how it plans to lift the lockdown restrictions. On Sunday government adviser, Prof Niall Ferguson told the Andrew Marr programme that the government had yet to finalise its plan.

British paediatrician and former WHO director Dr Costello says the government has been “too slow” to expand testing, especially in the community.

“The government’s tests will measure how many people have had the virus, and will show whether health workers are immune – but without community surveillance, tests alone won’t prevent its spread.”

Evidence from China and South Korea shows that community testing, contact tracing and quarantining, is a crucial component in controlling the spread of the virus and can be done at scale.

Hinting that mass community testing should be part of the government’s plan, Prof Ferguson said that far more swab tests were needed to track new infections and to trace and quarantine points of contact. 

He confirmed that 50,000 of these tests would be needed a day to allow ministers to start easing strict social distancing measures.

 

Variable and local plans needed

Monitoring the spread of the virus through the community opens the potential for a more tailored strategy, lifting restrictions depending on the local situation, an approach used by the Chinese authorities. 

The UK lockdown strategy has already attracted criticism as a blunt and imprecise tool. Devi Sridhar, professor of global public health at University of Edinburgh said: 

“Everyone in quarantine [is] not sustainable. It’s really expensive economically and socially. There has to be a safe way out of lockdown and I can’t see any other way than mass testing. We have to figure out who has the virus, who they are around, and change it so only they are in quarantine. 

Professor Allyson Pollock, a consultant in public health and academic at Newcastle University told the Guardian:

“The government needs to recognise that this isn’t just one big epidemic. It’s lots of outbreaks at different stages that all need to be tackled locally through local teams, and local action plans in each area so measures can be lifted over time.”

 

Mass testing is possible

At no stage has China moved away from community testing. In Wuhan – a city with a population of 11 million, more than 1800 teams of epidemiologists, each with 5 people collectively traced tens of thousands of contacts each day, quickly putting people into isolation.

Similar teams worked in provinces across China and a measure of their success is that 1-5% of the contacts they traced subsequently tested positive for the virus.

The first report on the Chinese response, by a 25 strong group of scientists, confirmed the importance of community testing, Dr Alyward the leading academic told the New Scientist

“To actually stop the virus, [China] had to do rapid testing of any suspect case, immediate isolation of anyone who was a confirmed or suspected case, and then quarantine the close contacts for 14 days so that they could figure out if any of them were infected,” 

Japan, Singapore and South Korea are pursuing mass testing and contact tracing throughout their outbreaks of the virus.

Learning from their MERS outbreak in 2015 South Korea has set up a network of 96 public and private laboratories to test for coronavirus. Drive through testing was available from early on in the outbreak, but later they introduced on-street testing, where the public can enter a booth, be tested and receive the result within 6 hours. 

In Singapore teams of police officers were recruited to help track contacts. UK academic Prof Allyson Pollock has suggested that an army of volunteers be recruited and trained-up to help with contact tracing, an idea that comes as the number of people signed-up to the NHS volunteering website has passed over half a million.

Prof Pollock also believes that the government has ignored some of its own key advice:

“The government’s evidence includes an important paper by Keeling et al on the impact of contact tracing on disease containment. This shows how, if basic public health measures are implemented, the transmission of the disease can be markedly reduced and the disease contained, without the draconian measures we are currently being subject to.”

 

Tech can help scale up testing, but what about privacy?

In the Chinese Province of Zhejiang a system of health QR codes was used by everyone in Hangzhou to track and stop the progress of the virus. Each individual was responsible for recording their temperature and updating their online profile. After filling out the questionnaire, users receive a colour-based QR-code, on their mobile phones indicating their health status. Green code allowed free movement, yellow required seven day quarantine whereas red a 14 day self-quarantine.

Following the Sars outbreak Laws were passed in South Korea to ensure the government could access data about people’s movements to help them track the disease. Messages are sent directly to phones telling South Koreans when a person in their district has been diagnosed with the virus and informing them about their whereabouts.

Some of these intrusive measures will be a step too far for many governments,  but US scientists have already called on Apple and Google to embed contact testing apps in their operating systems and suggested ways to preserve users rights and yet scale up the potential for identifying cases and enabling self quarantine.

“Apple, Google, and other mobile operating system vendors should work to provide an opt-in, privacy preserving OS feature to support contact tracing

In the UK software specialists at Oxford University are working on an algorithm inspired by the Chinese app to help individuals monitor their health and advise on isolation, which could be rolled out as part of the lifting of the lockdown.

An NHSX spokesperson told the New Statesman: “NHSX is looking at whether app-based solutions might be helpful in tracking and managing coronavirus, and we have assembled expertise from inside and outside the organisation to do this as rapidly as possible.”

But concern about privacy have been raised in an open letter to NHSX by a group describing themselves as responsible technologists

“There is little detail in the public domain about who will build the app, how it will work, how its effectiveness will be monitored and who will provide oversight over its proportionality and compliance with fundamental rights. It is unclear how data will be collected and processed, whether there are strict legal limitations on the purposes for which this data can be used now and in the future, how and where it will be stored, for how long, and who will have access to this data, either now or in the future.”

 

 

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Paul Evans
Author

director of the NHS Support Federation

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