Mass screening – a real scandal

Summary

• We are expanding the screening of people and youngsters with no symptoms or contact with Sars-Cov2.
• The scheme is causing far more problems that it solves with too many false positive and more false negative results.
• Oversight is poor and has needed Freedom of Information requests to find out what is happening
• It is currenlty costing between £3,000-18,000 to find each case.
• This is a part of the Governments Moonshot programme which has been estimated to eventually cost £100 billion, equating to £5,250 per family in the UK.
• In a sensible world, mass asymptomatic would be abandoned and the resources put into proven ways of managing the pandemic.

Introduction

I’ve never been a fan of mass screening of the asymptomatic having blogged about this last year. However it just seems to get worse and worse. Now that the number of cases is falling, finding positive cases is getting less likely and more expensive. Yet the Government plan to expand a scheme which seems to be of limited use and incredibly expensive at time when we are facing huge financial problems.

What’s going on?

The Government is now offering free tests to everyone who want them twice weekly. The word ‘Free’ needs to be taken with a pinch of salt as this process is costing a fortune. According to a report seen by the BMJ but ‘since removed’, the total costs of each test is in the range of £20 when all costs are factored in. Nevertheless it certainly makes for Number 10 friendly headlines – along the lines of BO-JO offering us all something for nothing! The daily papers almost all see it a pretty wonderful, as opposed to public health specialists – so let’s look at the reality.

Are the tests any good?

For me, the tests are really quite incredible. They are very specific with a tiny number of false positives, though far more false negatives. However, like all tests it’s how they are used that defines their effectiveness. This is where indiscriminate mass screening become problematical. We”come to the costs in a minute, but what about the accuracy?

The rate of positive tests among the asymptomatic population is just 0.1%, and the most optimistic assessment of the number of false positives generated by the Innova tests is 0.3% – this means that right now, for every real positive test, there are three false negatives. From the numbers above this means last week about 3,000 people are needlessly isolating.

Better tests might be coming along, but even with a false positive rate of 0.1%, with such low prevalence in the asymptomatic population, even this incredible specificity means that for each person who really had the infection, then one with a positive test will not. Worse still, this is going on while people with symptoms who really need to isolate are not doing so because of structural reasons of poverty and the need to continue working.

Further, the lateral flow tests will miss at least 40% of people who actually do have the infection, compromising their ability to reduce spread. Please Basil Faulty – make some sense of this!

What about schools and universities?

There has been screening going on in universities for some time now and what’s been found? For those institutions that reluctantly – after Freedom of Information requests – gave info to the British Medical Association, the results are pretty terrible. 335,383 tests yielded 1649 positive results, a rate of 0.5%, and the cost of finding EACH positive test? About £3,000 per case found! The Universities seem to have confidentially agreements with the Department of Health which prevent them from disclosing how effective, or costly the testing programmes are. I wonder why?

More incredibly still, most of the universities are not collecting data and a third are not even recording positive tests. Where they have, the results demonstrate the complete uselessness of testing – I would not flatter it with the term ‘programme’. Cambridge lead the way in terms of an ethical guide for testing and has made its data public.

In schools, where asymptomatic testing is rampant, its worse again – there is one positive test per 6,000 tests performed, giving a cost per positive test of a staggering £12,000. This is taking place in schools starved of investment where teachers are now working overtime to assess pupils not taking GCSE’s this year. As above, it has been justifiably reported that the return to school is being ruined by false positive tests.

The government have at least done a U turn for schools and now state that a PCR test should be done for those testing positive with a lateral flow test, and that if the PCR test is negative, isolation can end. This will add to the cost, and in schools, still mean reduce, though not eliminate the considerable ongoing disruption to education. A big motivation for this is to monitor the prevalence of the Kent variant, which can be detected with the routine PCR swab.

What do the government say?

Susan Hopkins, who is leading this at PHE offers an unconvincing: “rapid testing might find cases that would not otherwise be discovered”. The big word there is MIGHT. ‘Handsfree’ Hancock is developing an expertise at avoiding any of the real issues when he says “regular rapid testing is going to be fundamental in helping us quickly spot positive cases and squash any outbreaks.” No mention of the missed case, false positives or the cost.

The The Innova story is a scandal of procurement in itself. The Innova contract is worth nearly £500 million added to an earlier taster costing £107. The company is based in California, owned by the equity group Pasaca Capital and founded by a Chinese Investment banker in 2017.

Despite all this, not only does the role out continue, it is expanding. The many problems with accuracy, effectiveness which are being dwarfed by its staggering cost.

What to do?

In a sensible world the whole fiasco would be brought to a juddering halt and the test could be used to sensible screen people with symptoms or in certain situations. Pilots tests to assess effectiveness in mass events will be interesting, though with low prevalence might give clear results on their use in this situation either.

However, contracts are contracts and along with Bo-Jo friendly headlines these might be the driving force for now and perhaps we will have to wait until the mountain of these tests we bought so unwisely have been used up?

Now that prevalence has fallen to a level where all cases could theoretically be rapidly found and ongoing spread halted, development of the testing, tracing, isolation and support systems needs to happen, particularly in the successful public sector. This key foundation for pandemic management has not been put in place with only about half of people with infections isolating leaving us vulnerable to unchecked small fires growing in to big ones.

Opportunity lost

The other consequence of all this is what is termed the opportunity cost. There are many ways in which money could have been spent so much more wisely in terms of return. Climate change remains a greater threat to humanity by orders of magnitude, and the lateral flow testing scheme will have diverted resources away from the rebuild of society desperately needed. I also think of the mountain of plastic waste from the millions of discarded tests, soon to be incinerated to joining the rest of the CO2 with which we are busily poisoning life on this planet.

Opportunity cost matters!