Flaws in Liverpool’s pilot mass testing scheme reveal the risks of Operation Moonshot

Mass testing is poised to be rolled out across nearly one hundred different Tier 3 areas in England once the nationwide lockdown ends on 2 December. Liverpool’s pilot scheme is being used to justify this next phase of the £100 billion testing project, Operation Moonshot, but the results of the city’s experiment are messy and inconclusive.

In mid-October, Liverpool was one of the worst affected Covid hotspots in Europe with an infection rate four times greater than the national average. To combat the spike, the city was singled out as a guinea pig for a mass testing experiment. The scheme launched on 6 November with the aim of reducing infection rates by detecting asymptomatic cases early. Anyone living or working in Liverpool could get a test. Some 2,000 soldiers were drafted in to set up dozens of testing sites in council buildings, schools, community centres and Anfield Stadium.

Now, three weeks later, cases have fallen dramatically from their October peak, so much so that Boris Johnson labelled the city as “a success story which we want other parts of the country to replicate.”

The Liverpool City Region has been granted a reprieve in the new tier system, moving down a rung from Tier 3. “Liverpool had to be in Tier 2 to show you can turn these things around,” said one minister who attended the secret meeting last week to decide regional restrictions.

Matt Hancock was keen to give mass testing a slice of the credit. “They’ve found a load more people who were asymptomatic, didn’t know that they had a problem, didn’t know they have the virus,” he said. “The combination of the mass testing and the measures in Liverpool have brought the cases down really quite remarkably, much faster than I would have thought was possible.”

The pilot has had some success. Around 110,000 Liverpool residents have so far taken the Innova “lateral flow” antigen test – which returns results in 20 minutes – and 721 positive cases have been detected. A localised tracing system has helped to speedily track down close contacts and ask them to isolate. Many of these cases would not have been detected otherwise and lives have almost certainly been saved as a result.

But the idea that testing is to thank for Liverpool’s recovery is undermined by the fact that the bulk of the infection rate reduction happened before the pilot was introduced. At the peak of the second wave in early October, the infection rate in Liverpool stood at just under 700 per 100,000. The city was placed in Tier 3 a week later.

By November 6, when mass testing and a second nationwide lockdown were introduced, the number of new cases had already fallen dramatically to 267 per 100,000. The reduction to 174 per 100,000 today is modest by comparison, and a significant fraction is likely to have been the result of lockdown.

Calum Semple, Professor of Outbreak Medicine at the University of Liverpool, who helped co-ordinate the study, has praised the “huge community engagement” with the pilot.

But if you consider that Liverpool’s population is 500,000, and you add in those who travel to the city to work, then only around 20% of those eligible to be tested have chosen to do so.

Scotland’s national clinical director, Jason Leitch, has cited the “disappointing” engagement in the Liverpool trial as the reason why only smaller towns will be considered for mass testing in Scotland.

Dr Rob Barnett, secretary with the Liverpool Medical Committee, has warned that the testing scheme will be a “missed opportunity” unless engagement improves. In some of the city’s most deprived neighbourhoods, just 4% of residents volunteered to get tested.

One likely reason is that incentives to get tested are skewed – why get tested and risk losing two weeks’ income by having to quarantine? – and the less well-off feel this most acutely. Many consider the government’s £500 self-isolation support grant to be too meagre and the criteria to qualify for it to be too strict.

“There is no doubt if you compare the figures to the figures three to four weeks ago, Liverpool is in a much better place,” Dr Barnett said. “But the figures are… still too high [and] we’ve got too many people in hospital.”

“If we can’t get more people tested, if it is only the worried well in affluent areas, then actually we won’t do what’s needed to get the city out of the mess it’s in.”

Concerns about uptake feed into the wider objection that mass testing is a hugely costly and still unproven approach. In a joint statement, the Faculty of Public Health and the Association of Directors of Public Health said: “The additional capacity provided to Liverpool to set up and manage testing sites alone has been enormous and it is difficult to envisage how or even whether this could be replicated at the pace being proposed across the country.

“This threatens to be a distraction from other activities, like planning and rolling out vaccines.”

Their statement added: “The key priority needs to be targeted community testing… in settings or locations of higher risk of transmission or where the consequence of infection is higher.”

Allyson Pollock, Professor of Public Health at Newcastle University, who also sits on the Independent SAGE committee, said there was “insufficient evidence” for rolling out what amounted to an “extraordinary experiment across the whole of England where the purpose is far from clear.”

Mass testing schemes also risk causing harm through “significant diversion of healthcare resources,” according to Pollock. “We do not know, based on current evidence, whether screening the general population for SARS-CoV-2 will increase or decrease disease transmission, hospitalisations, and deaths,” she said.

As mass testing expands, test accuracy will become a big issue. The Innova test being used in Liverpool returns very few false positives but just 77% of people who have the virus test positive. The rate drops to just 58% if the test is not administered by a trained professional. This low sensitivity will become increasingly problematic as restrictions are loosened as those falsely told they’re negative will have more opportunity to spread the virus.

The Liverpool pilot’s ambiguous impact has not made the case for mass testing and fundamental flaws remain. Expanding the scheme – at vast cost – remains a huge gamble.