One of the many ways in which the government has badly mishandled the response to the Covid19 pandemic is its failure to carry out widespread testing, contact tracing and isolation of all who test positive and their contacts.
As the World Health Organisation has repeatedly pointed out, early case finding, testing, contact tracing and isolation is essential for stopping transmission of Covid 19. Countries like S Korea and Germany that have done this have had much lower rates of infection and deaths.
It is also essential when control measures like lockdowns are lifted. Covid 19 infections accelerate very fast, but they decline much more slowly. Control measures can only be lifted if the right public health measures are in place – including significant capacity for contact tracing.
What test are we talking about here?
The so-called PCR (Polymerase Chain Reaction) test shows active infection, by looking for genetic material associated with Covid19. The test is carried out using a swab to collect specimens from the top of the nostrils and the back of the throat.
In early March the NHS’s whole Covid 19 PCR testing capacity was just 1500 tests a day. This was barely adequate to deal even with the sharply rising number of suspected COVID-19 patients being admitted to hospital, let alone test patients in the community who were coping with the symptoms of Covid-19 at home. Community testing – and contact tracing – ended on March 12th – with consequences we now know to have been dire..
Why has Public Health England – the government’s responsible quango – failed to provide adequate testing capacity?
The roots of the problem lie in the 2012 Health and Social Care Act. It abolished the Health Protection Agency, that was responsible for protecting the population in health emergencies. Its staff were dispersed among 150 town and county councils.
David McCoy points out that by 2020, central government budget cuts had reduced these staff to impotent teams of as few as two or three people.
Writing in the British Medical Journal in 30 March, Prof Allyson Pollock confirmed that
“The decrease in numbers of consultants in communicable disease control and community control teams, together with swingeing local authority cuts since 2010, have reduced the chances of a strong local response. Local pathology and virology services have been centralised and partly privatised, leading to a fragmented mix of for-profit and public laboratories and serious staff shortages.”
In addition, the abolition of the Health Protection Agency meant that by the time the pandemic struck,
“The Chief Medical Officer (CMO) was no longer in direct charge of managing pandemics, but only one adviser among others, with no budget. A symptom of the consequences was that serious shortcomings in pandemic preparedness revealed in a routine exercise in 2016, and reported by the then CMO, were not acted on.”Colin Leys, https://prruk.org/the-uk-response-to-the-covid-19-pandemic/
With no responsible organisation possessing resources, status, or implementation capacity on the ground, hospital microbiology labs faltered – even though they are capable of carrying out Covid 19 PCR testing.
UK’s first non-Public Health England covid-19 testing
In February this year, the microbiology team at Basingstoke North Hampshire Hospitals set up the UKs first non-Public Health England covid-19 testing, working with a local company called PrimerDesign.
Primerdesign says it is the first European Medical Device manufacturer to have launched a detection test for the novel Coronavirus (2019-nCoV). On the back of this announcement, the share value of its parent company Novacyt, rocketed.
Primerdesign’s kits are available immediately to purchase on their website and can be distributed globally.
Since then, the Basingstoke hospital has been testing for the virus and is able to get a result in 12 hours.
But this initiative has not been widely replicated by other hospital microbiology labs.
Update 29.11.2020 The Independent reports that
“As part of Operation Moonshot, Downing Street ordered 300 high-tech PCR testing devices designed by Primerdesign…which were due to be placed in clinical settings across the country…
However, The Independent understands that the government is now reassessing the testing platform after NHS officials and biomedical scientists flagged concerns over the machines – 200 of which have so far been delivered to hospitals…
A second rollout of the devices, which would have seen the remaining 100 kits installed in English hospitals, is now under review.”
Despite everything, in February Britain was containing Covid19 quite well through testing, tracing and quarantining
Despite all these systemic problems, in February, according to a Guardian report Britain was still doing quite well in containing the disease by testing, tracing contact and setting up quarantine for those suspected of being infected with Covid-19 at this time.
“Then, in March, the government decided to abandon this approach and shift from containing the disease to delaying its progress. I would really like to know why the decision to give up testing and contact tracing was taken.”Tom Wingfield, a clinician and infectious disease expert based at the Liverpool School of Tropical Medicine, talking to the Guardian https://www.theguardian.com/world/2020/apr/18/how-did-britain-get-its-response-to-coronavirus-so-wrong
The government’s decision is particularly baffling, given modelling conducted by the authors of ‘The Efficacy of Contact Tracing for the Containment of the 2019 Novel Coronavirus (COVID-19)’ (Keeling et al.). This was one of the Scientific Advisory Group for Emergencies papers that the government published on 20 March.
Based on their modelling, the authors expected that contact tracing would enable the Covid19 outbreak to be contained,
“Aggregating across all individuals and under the optimistic assumption that all the contact tracing can be performed rapidly, we expect contact tracing to reduce the basic reproductive ratio from 3.11 to 0.21 – enabling the outbreak to be contained (figure 2). Rapid and effective contact tracing can therefore be highly effective in the early control of COVID-19, but places substantial demands on the local public-health authorities.”
Why did community testing stop?
Was it lack of local public health capacity that drove the decision to abandon the test, trace and quarantine approach? Community testing stopped on 13th March. Until then PHE’s contact tracing response team of around 300 people, working around the clock, had traced 3,500 people and supported the 3% of contacts found to be infected to self-isolate.
After the March 12th Cobra meeting, the definition of who can be considered as a possible Covid 19 patient broadened.
Travel to specific Covid19 hotspots, or contact with someone who had, was no longer a requirement for a suspected Covid19 infection. The virus was now obviously being transmitted in the UK – not just confined to those who caught it abroad and their known contacts.
The new definition said you are considered as possibly Covid 19 positive if you fall into one of these two categories:
- A hospital health professional decides you need admitting for at least one night and you have either clinical or radiological evidence of pneumonia, or acute respiratory distress syndrome. or influenza like illness (fever ≥37.8°C and at least one of the following respiratory symptoms, which must be of acute onset: persistent cough (with or without sputum), hoarseness, nasal discharge or congestion, shortness of breath, sore throat, wheezing, sneezing)
- You have a new continuous cough and/or high temperature, but are well enough to stay home. In that case, you will not be tested and will be expected to self-isolate for 7 days unless your symptoms worsen and you contact NHS 111 for help.
The government just threw up its hands at that point, in terms of a public health approach to containing Covid19. Why? (Update, 19.5.2020: The SAGE advice must now be published.)
It was not for want of people to do the contact tracing.
By stopping contact tracing on March 12th, Government allowed Covid19 to spread
According to the Chartered Institute of Environmental Health, Councils employ 5,000 contact tracing experts in their environmental health departments, who routinely carry out contact tracing in outbreaks like norovirus, salmonella or legionnaires’ disease. But Public Health England decided not to use them to contain Covid 19.
When the government decided to stop contact tracing on 12 March, there had been 10 Covid 19 deaths and 590 confirmed cases, and about 3,500 contacts had been traced. Most were were in London and the West Midlands.
Continued testing, tracking and tracing could have kept the virus out of other regions and reduced deaths, according to Anthony Costello, a professor of global health and sustainable development at University College London and a former WHO director.
“If we hadn’t stopped it on 12 March, our epidemic would have been much less. They effectively allowed it to spread.”Anthony Costello, reported in the Guardian https://www.theguardian.com/politics/2020/apr/28/contact-tracing-cant-be-run-by-westminster-experts-warn
Public health, local government and environmental health officers all say they are capable of running the sort of extensive contact tracing network needed in all areas of the country.
Dr Jeanelle de Gruchy, the president of the Association of Directors of Public Health, said,
“Directors of public health – and their teams – have extensive experience and knowledge of contact tracing, their local communities and the wider health and social care system.”
What have West Yorkshire hospitals’ microbiology labs done?
I have asked Calderdale and Huddersfield hospitals trust whether their microbiology lab has been doing Covid-19 PCR testing. On 21 April, the hospitals’ comms staff replied that the lab have done 1675 COVID PCR tests so far. They do 96 tests a day and the turnaround time in 24 hours. Which means that they must have started testing on 3rd or 4th April.
I have heard that no PCR testing has been done at Pinderfields at present: but since the last week in March they have been doing the extractions for Leeds on the Covid-19 samples they have been receiving. That way, it saves Leeds some time in that they can get them straight onto the next run.
Pinderfields are getting results from Leeds the following day: positives are being phoned to the lab. They have managed to get NPEex set up so that negative results come straight across to iLab (and ICE) once Leeds enter the result. Negative results are automatically authorised.
Leeds General Infirmary was the only Virus Testing lab in Yorkshire and Humber listed by Public Health England in its 16th March 2020 ‘Guidance and standard operating procedure – COVID-19 virus testing in NHS laboratories’.
A (leaked) 19 March email from Jim Taylor, York Medical Director for Professional Standards, referred to “significant delays due to capacity issues” at the Leeds lab, which he “expected to get worse if no new capacity is developed.”
For this reason, the advice at the time was not to test NHS staff as there was “insufficient national testing capacity for patients”.
An informed person has told me,
“Capacity at Leeds is a permanent issue – they have problems recruiting and retaining staff.”
On 17 April, Stacey Hunter, Executive Director for Acute Provider Collaboration Bradford FT and Airedale FT, tweeted:
@BTHFT @AiredaleNHSFT fantastic work by the pathology joint venture providing same day results for our population . Taken a lot of hard work and planning behind the scenes by our dedicated Pathology team @JaneMills2
Government scrabbles to expand NHS testing capacity
On 24th March, The Royal College of Pathologists reported ,
“Currently, 10 NHS microbiology services have been asked to step up capacity. The next phase will call on 29 NHS pathology networks to allocate further testing to their 122 services while ensuring day to day analysis for other conditions continues.”
By 1st April, in response to Matt Hancock’s call to “ramp up” testing, Professor Jo Martin, President of The Royal College of Pathologists, updated:
“Our members have been working extremely hard, and really well, in ramping up testing for COVID-19…
There have been significant challenges and barriers to increasing capacity for testing across all labs, not least due to issues with the supply chain for testing materials. We have been working with government to try resolve these issues and we will do what we can to help our members to meet the challenges ahead, and to get the testing and clinical support in place for all those who need it.”
On 2nd April, the government published a call to businesses to increase testing capacity in the UK.
Cost-cutting centralisation of West Yorkshire Pathology Services may affect resilience
Only last year, a Yorkshire NHS trust rejected their microbiology managers’ business case for carrying out PCR testing. This was before Covid, but was an effort to manage other outbreaks (Norovirus, seasonal flu etc) more effectively, due to the excessive turnaround time for testing in Leeds.
This rejection may come as no surprise, since the West Yorkshire Association of Acute Trusts Pathology initiative has been clear from start that the intent was to cut Microbiology labs and centralise at Leeds.
The centralisation of Pathology Services in our region has been imposed by the quango NHS Improvement, in order to cut costs across the West Yorkshire and Harrogate Integrated Care System by £8.8m. This is on a budget of £71million for Pathology overall.
Much of the cuts will come from staff ‘savings’ though economies of scale: the Pathology Services centralisation looks likely to be implemented in such a way that existing Microbiology hospital laboratories in Mid Yorkshire, Calderdale, Airedale and Harrogate will be drastically reduced, with many services being centralised in a new laboratory at St. James Hospital in Leeds. The workforce will be ‘re-profiled’.
An October 2019 West Yorkshire Association of Acute Trusts (WYAAT) presentation confirming their intention to centralise Microbiology at the new Leeds lab openly acknowledged that this may affect resilience. But WYAAT justified this by spurious claims of clinical effectiveness and saving money. Whether this view will stand after the current pandemic is reviewed is open to question.
There have been desperate calls for Covid19 testing to be provided by non-NHS labs to ease the burden. This would only be exacerbated if there were even fewer hospital labs to begin with! There are also concerns about tests done in non-NHS labs that have not been accredited to UKAS standards by staff that are not registered with the Health and Care Professions Council.
With the Covid19 pandemic, the Yorkshire microbiology lab that was refused funding last year to carry out PCR testing has been given some money to procure a PCR machine. The machine is coming from R-biopharm, with a lead-time of 4-5 weeks.
NHS staff testing
Bradford NHS staff can now be tested in the first 3 days of Covid 19 symptoms, on the basis of referrals from their employer/ GP practice. Helen Hirst, the Bradford CCG Chief Officer, has tweeted that,
“The swabs are collected each day and taken elsewhere. The test kits and analysis have been nationally sourced. We just do the doing the rest is organised nationally.”
On 24th March, a central Coronavirus test centre was set up in Milton Keynes to run the PCR tests for active viral infection. The BBC Milton Keynes news website , made it clear that the testing is aimed at
“Healthcare and key workers [who] are currently being sent home if they show any symptoms at all but could possibly continue working if they tested negative.”
I have asked Calderdale Clinical Commissioning Group where NHS staff in Calderdale can get Covid19 tests but have had no reply.
In Huddersfield, covid 19 testing for NHS staff is apparently being carried out near Greenhead College.
No serology testing (to detect antibodies that show past infection with Covid 19) is being done as yet.
In late March, the government announced to great excitement that it had bought 3.5m covid19 antibody tests, claimed that this was a game changer and then found none of them work.
Following massive public criticism about the lack of testing, on 2nd April Matt Hancock announced antibody testing was one of 5 “pillars” for Covid19 screening,
“reliable and accurate antibody testing that are scalable, resilient and scientifically robust”.
But the actual point of developing these tests seems unclear – at the moment no one knows whether the presence of antibodies means people have developed immunity to Covid19, or how long immunity would last.
So who is going to benefit – apart from companies that manage to produce the tests to the government’s specifications, and that carry out the testing?
Ten years ago, we had a perfectly good public health service that included an organisation dedicated to protecting the population in health emergencies. Successive governments have destroyed that service.
Government’s duty to protect citizens can’t be palmed off onto private companies
When we come out the other side, a key task will be to rebuild the public health service and the government’s capacity to protect the population in health emergencies. Attempts to continue the fragmentation and privatisation of these services simply will not wash. The prime duty of governments is to protect all citizens. It cannot be palmed off onto private companies, whose main concern is inevitably shareholder profits.
On 27 April, Primerdesign’s parent company, Novacyt, announced it had signed a contract with the Department of Health and Social Care. From 4th May, Novacyt will supply 288,000 diagnostic tests per week for use in the NHS for an initial six months. There is an option to extend the agreement.
Photo credit: Leeds Live
Updated 19.4.2020 with info from this Guardian report and sections on the government’s abandonment of community testing.
Updated 21.4.2020 with info about Covid19 testing at CHFT microbiology lab and PHE’s failure to use Councils’ environmental health contact tracers.
Update 1.5.2020 with info about Primerdesign’s parent company’s contract with DHSC for 288K diagnostic tests/week
Updated 3.5.2020 with info about Anthony Costello’s statements and link to Guardian article about need to resume contact tracing and isolation support , run by local Directors of public health.