Over-centralised, ineffective government Covid strategy needs to embrace targeted testing among vulnerable groups

Results from the Oxford/AstraZeneca phase 3 vaccine trial are expected by the end of the month. Hopes are high following the announcement that a second vaccine, developed by Moderna, appears to be 95% effective. The findings come just a week after Pfizer released similarly impressive data. The good news keeps on coming.

Vaccines will be vital in controlling Covid-19 but, as we are reminded by the temporarily excited though innately cautious scientific community, they are no silver bullet. It is most likely to be several years before vaccines suppress the virus globally. Despite the good news, an effective policy response is just as important as ever.

This leads us back to the question we’ve been asking since March: can the government work out a coherent coronavirus strategy?

Fresh scorn is being poured on the beleaguered Test and Trace system after the app ordered Boris Johnson to self-isolate for two weeks despite only a minute chance that he is at risk; if the PM becomes infected, he would be just the twenty-sixth confirmed reinfection out of over 50 million cases worldwide.

Whether or not the rules make sense, the practicalities of the scheme have proven to be nightmarish. Backlogs of unprocessed tests have delayed results and IT errors have plagued a system that has struggled to keep up with demand.

“How effective a testing system is depends on what you do with the test results,” according to Professor Hugh Pennington, professor of bacteriology at the University of Aberdeen. He told Reaction that “one of the big weaknesses with contact tracing is that not everyone gets contact traced, which means the whole programme is a waste of time, or not far off it.”

Although around 330,000 Test and Trace tests are being processed every day and 85% of positive cases are contacted, only 60% of close contacts are reached and told to isolate. Surveys suggest that just 20% of those asked to isolate actually do so fully.

The root of the problem, according to Matthew Lesh, Head of Research at the Adam Smith Institute, is that the system is too centralised.

“The government is using a small number of ‘Lighthouse’ mega-labs to process all the country’s tests,” Lesh explains. “There are logjams because of the tricky logistics of getting all the tests to a central point. It would be much better to commission many smaller labs.”

“The tracing element has been centralised as well. Rather than using the public health knowledge and teams that exist on a local council level, they decided to develop a whole secondary national system based on call centres without any sort of local tracing coordination.”

Running alongside the beleaguered tracing programme is Operation Moonshot, the highly ambitious, £100 billion mass testing scheme. In its essentials, the idea behind the operation is that anybody should be able to get tested whether they show symptoms or not. The approach would mean that asymptomatic cases – which also spread the virus but which are usually missed – would also be detected and outbreaks could be contained without the need for blanket restrictions.

Mass testing is currently being trialled in Liverpool, where anybody living or working in the city can book a lateral flow antigen test, which delivers a result in around 30 minutes, unlike Test and Trace’s PCR test, which has to be sent off to a lab.

The pilot is the first step towards embedding testing in our daily lives. In an ideal scenario, people across the country would take a test before going to the theatre, to the football, into the office or onto a plane.

“Currently, we ask people to give up 14 days of their lives whether or not they have the virus,” says Lesh. “If we test people all the time we don’t need to isolate indiscriminately and tracing becomes less important.”

Mass testing faces fierce criticism, however. A report published this week by Independent Sage – a group of scientists providing independent scientific advice to the UK government – has warned that Moonshot is likely to be expensive and ineffective as it needlessly allocates resources away from specific groups that need tests the most, such as care home visitors or close contacts of infected cases.

One of Independent Sage’s members, Professor Allyson Pollock, clinical professor of public health at Newcastle University, said: “We’re arguing the ‘Moonshot’ program really should be paused until the cost-effectiveness is well established.”

There are growing calls for a more targeted rapid testing approach. “We have a choice,” says the entrepreneur and biotech investor, Hugh Osmond. “We can protect all hospital and care home patients, which would mean protecting about 550,000 people in 12,500 locations across the country. This could reduce the death toll by 70 or 80 per cent.

“Or, we carry on what we’re doing – trying to stop infections in 67 million people by shutting down society, wasting a huge amount of people’s time quarantining while destroying their lives and income.

“Mass testing of healthy people doesn’t achieve anything. We should use rapid tests at the point of intersection between the wider community and the vulnerable community.”

The Independent Sage report also highlighted the high false negative rate of rapid lateral flow tests. The Innova test being trialled in Liverpool returns very few false positives; in trials, 99.68% of people who did not have the virus tested negative. But just 76.8% of people who did have the virus tested positive. The tests work best if there is a high quantity of virus in someone’s system.

Pollock said: “That is one of the myths that’s being propagated … that you could have your test in the morning – and if you were negative you could go about your business or go to funerals, or go to the nursing homes, and you’ll be fine.”

A number of different rapid lateral flow tests are in development. If accuracy is improved, then targeted rapid testing could offer the flexibility of a decentralised system without the costly overreach of a blanket approach. For a government in need of a strategy, this could be a winning formula.