AAll eyes are on vaccines, waiting and yearning, but when immunization comes, testing and screening will remain essential for a long time to keep the virus suppressed due to staggered program implementation or resistance to absorption. But the way you test is critical. It must be based on a wealth of experience, not a novel approach with the potential to waste colossal sums of public money.
Sir Muir Gray, an expert in projections writing in the BMJ – along with Mike Gill, England’s former regional director of public health – has just delivered a devastating verdict on the efficacy of the testing program now being tested in Liverpool, with mega-labs. opening next year.
Needless to say, Gray has not been consulted, despite being the author of the standard text on screening and founder of the National Screening Committee in 1996, which corrected a chaotic cervical screening program. I was on that committee for several years as he forged the criteria for what makes a screening project effective, what conditions, and what protocols.
You are surprised to find that this comprehensive assessment of the entire Covid-19 population has not even been brought before the committee. He writes: “If judged by the criteria set out by the UK National Selection Committee to assess the feasibility, effectiveness and adequacy of a program, it does not perform well and has already been roundly criticized.” Interpret that as “very bad” on all the measures that detection plans are typically evaluated by.
I learned from him on the committee, and he now reminds me that when screening proposals are presented: “All screening programs do some harm with false positives and false negatives, some do more good than harm, and some do more good than harm to a reasonable cost. ”That should have been weighed in the balance before the massive Covid detection, which finds that it fails.
The Innova test, one of two used in Liverpool, has not been evaluated under these conditions. Gray writes, “The test’s instructions for use state that it should not be used in asymptomatic people,” in other words, not for wide-population screening. A evaluation by Porton Down and the University of Oxford suggests that “the test fails between one in two and one in four cases. The 0.6% false positive rate means that, with the current prevalence in Liverpool, for every person found to be truly positive, at least one other may be wrongly required to isolate themselves. “
When an infection is detected, “few currently adhere to self-isolation,” with 20% being an estimate. Gray notes with his usual dry understatement that “this is an obvious area for improvement before we embark on a costly screening program.” Also, low-income people are less likely to come forward for screening for fear of having to isolate themselves. That underscores, he writes, “the importance of reducing the rate of false positive results and providing adequate financial, psychological and material support to people who must isolate themselves.”
As the TUC, the Labor Party and many other critics pointed out long ago, those with the lowest incomes, those most at risk, are the least able to afford to take time off work, frustrating the entire effort. Gray suggested to me when I called this week that everyone should get at least the same as jury duty: £ 65 a day. In Germany, everyone is rewarded for their full salary. Why waste £ 100bn without this obvious need?
Gray reveals, astonishingly, that “there is no protocol for this pilot in the public domain, much less system specifications or ethical approval.” Spending this monumental sum cannot be defended “on an under-evaluated and poorly designed national program that leads to regressive and insufficiently supported intervention, in many cases from the wrong people.” But maybe, I ask you, in this crisis, was there not time? He says the National Evaluation Committee could have looked at it, setting the right targets, “in a week or so.”
There are firm rules on detection. “You never get 100% participation”, but if done correctly, “you can reach 80-90%.” Getting the last 5% can cost as much as reaching the first 90%, but, he notes, in this case, the hardest to reach are the ones you need the most.
In my time on the committee, preventing poor selection was often the key task. Schemes that seemed brilliant at first glance may turn out to be silly. Gray reminds neurosurgeons who said screening tests could prevent strokes if all middle-aged people with an atypical headache were sent for screening – the numbers would have been unmanageable. There was frequent pressure to screen the prostate with PSA tests: groups of men said it was unfair that women had spent so much on breast cancer. But it would have led to unnecessary surgery, with the risk of incontinence and impotence for many men who would have died of something else long before prostate cancer developed. The prenatal ultrasound at first noticed any small irregularities without knowing their importance: the result was that too many women were sent for an amniocentesis, with a 1% miscarriage rate, so clearer ultrasound verdicts were imposed. Early detection of breast cancer detected all microcalcifications, which may never turn into cancer, for excision. Bad screening programs can cause fear and harm.
Gray calls for “an immediate pause” for this massive Covid assessment of the asymptomatic, until it is reviewed by the National Assessment Committee. A negative test may mistakenly feel like a path to freedom, but that’s “premature,” he warns, without improving “the woeful performance of the ‘find, test, track and isolate’ system.” Focus first on those with symptoms among the highest risk groups, with good compensation for those who are told to isolate themselves.
This gigantic projection plan has all the worst characteristics of Johnsonism: He labels it “Operation Moonshot” and gives it to Dominic Cummings, who is ignorant of the projection experience. Cummings is gone but still control of the massive test. That £ 100 billion is a staggering sum, almost three quarters of annual spending across the NHS. Imagine what that could buy, especially to “level up” the lives of those most at risk from Covid-19.
• Polly Toynbee is a columnist for The Guardian
Digsmak is a news publisher with over 12 years of reporting experiance; and have published in many industry leading publications and news sites.