The case for mass testing

This morning, Matt Hancock claimed on the Today programme that the government is now working as fast as it can on developing a mass testing programme, which is ‘incredibly important’ if we want to ease coronavirus restrictions.

The health secretary is right to finally focus on mass testing. So far, the UK’s performance has been relatively poor in fighting the pandemic, and we are currently expected to come out among the worst in the two-by-two matrix comparing Covid-19 performance on deaths and forecast economic impact:

While some of this is structural – we have an economy that is more exposed to the service sectors than others and our population is more overweight, more diabetic, travels more on congested mass transport and lives more in multigenerational housing – we, citizens, businesses and the Government, have not played Covid-19 well to date. The core of our strategy for the next phase is the Test, Track, Trace and Isolate Programme. This works by finding close contacts of people who have tested positive for Covid-19, and then isolating them before they can spread the virus further, building on the infectious disease containment strategies used by the likes of South Korea for Middle East Respiratory Syndrome in 2015.

But applying this approach to Covid-19 in the UK faces two main obstacles. Firstly, while for Middle East Respiratory Syndrome only 15 per cent were asymptomatic, with Covid-19 between 40 and 75 per cent of Covid-19 patients are estimated to be asymptomatic, so many more don’t feel ill enough to go for a test. This high asymptomatic proportion explains why fewer than one in five of people with Covid-19 are tested in England. The second potential obstacle is that we Brits don’t generally ‘grass on our friends’ and have become somewhat indifferent to the Government’s advice. For Test and Trace to work, we need those testing positive for Covid-19 to name all their recent close contacts, prioritising the good of the country over the good of their friends. I lived in South Korea for six years and saw this kind of behaviour frequently. But in the UK, my informal surveys suggest that many people will not hand over the names of all our recent close contacts – especially those we know would suffer economically from having to self-isolate. We can see this in the tracing numbers: 20 per cent of those testing positive were ‘unable to provide any contacts when reached’ (my emphasis). As I have pointed out previously, we see the impact of all of this in the poor performance of Test and Trace. Despite ministers pointing that performance on some statistics are improving (such as the number of close contacts reached), the aggregate performance is still dismal. For every person successfully isolated, the process misses around 20 people who potentially will continue to spread the infection. Clearly this level of performance will not be sufficient to prevent a second peak as we restart. We need to rethink the whole Test and Trace strategy and redesign our approach to testing to reflect the asymptomatic nature of the disease. We cannot rely on citizens realising they have Covid-19 and applying for a test. Instead we need to take testing to the people through a programme of mass testing. We need to supplement our highly accurate but slow, expensive and painful swab-based laboratory analysed testing with cheaper and less painful home tests, even if that means sacrificing some accuracy. This week, it was announced that Public Health England will be replaced by a National Institute of Health Protection, which might help drive this change – though the history of government health reorganisations does not bode well.

To illustrate mass testing, imagine a world that every third morning we all self-administer a test at home, with the results available within 10 minutes. If the test is clear, we go to school, work, etc. If it shows we have the virus, we isolate and take a more accurate test. Or imagine a world where departing travellers blow into a tube connected to a Covid-19 test machine before entering an airport. Or a world where those in the queue for a live arts or sports event take a salvia test giving results in minutes. Or a world where a detector in the sewer of an office building or care home picks up traces of Covid-19, prompting a test of all in the building. These are all examples of mass testing and as they don’t rely on the citizen feeling ill, are able to find the asymptomatic, and so produce better aggregate performance even if the individual tests have lower sensitivity. They rely on good behaviour in self-isolation, but are not as dependent on us ‘grassing up’ our friends by sharing close contacts. A mass testing regime will require us to test tens of millions of citizens per day, as opposed to our current target of 500,000. The good news is that all of the technologies these examples use are available at least in pilot form and are probably closer to mass availability than vaccines (I have to declare a conflict here as I have invested in some of the potential innovators). These tests should be available at very different price points from the current high-quality laboratory-based test. Professor Michael Mina of the Harvard School Public Health has identified a number of biotech firms with proven technologies and believes that the cost of these tests could, over time, fall to a lot less than £5 a test. The cost of mass testing could become similar to the cost of the current approach to Test and Trace, and a small percentage of the billions a day lockdown costs us. Moving to an approach of mass testing will require the Government to accelerate the building of a UK mass testing diagnostic industry. Ministers are now talking about mass testing, which is a good, but late start. The Government has also launched the Condor (Covid-19 National Diagnostic Research and Evaluation Platform) programme funded by the National Institute for Health Research, which prioritises and evaluates novel coronavirus diagnostics in the UK. Its leaders seem to understand that there are different segments of tests with different ease of use, pain of administering, time to result, accuracy and cost. This is unlike the US FDA that seems to currently require the same performance standard from all tests. However, aside from the NIHR programme, the UK seems to be underinvesting in mass testing capabilities. Compare the £1.3million we are spending on Condor with over £100 million we have invested in vaccines. If we are to get mass testing to work, we need an industrial strategy to quickly scale the UK mass testing industry and drive down the cost per test. We also need to develop the logistics and communications around mass testing, which will not be simple. But if mass testing can be made to work, we will have a system that could deliver – unlike the current approach which is destined to underperform, given the asymptomatic nature of Covid-19. Indeed, if we could harness the creativity, that was able to mass produce ventilators and open the Nightingale Hospitals in less than ten days, to build the manufacturing and application of mass testing, we could really say that the UK has a world class Test and Trace programme, and more importantly stop Covid-19 in its tracks.