COMMENTARY

UK's COVID-19 Testing 'Cobbled Together'

Prof Karol Sikora

Disclosures

July 15, 2020

This transcript has been edited for clarity.

Hi there, it's Professor Karol Sikora here. I'm an oncologist and I'm talking about measurement in the era of coronavirus.

You know, in cancer, we're absolutely assiduous about what we do with measurements. We take X-rays, images, tumour markers, blood tests, to try and assess how far a tumour has spread and how it's doing. We then give an intervention, chemotherapy, radiotherapy, and we do the same measurements again. We understand the value of getting precise metrics to follow what's happening with cancer.

I'm not an infectious disease physician, but I can see the benefits of measurement in corona. And to be honest, we've done it very badly in the UK, or at least public health services have not been on top of the measurement of this pandemic. It's been cobbled together by a government that doesn't really understand the science behind it all.

Measuring a Pandemic

If we begin with that. What measurements can we make to sort things out in a pandemic?

Number 1 is the incidence of infection.

Number 2 is the number of hospitalisations. That's fairly simple. You just count the number of people coming into hospital. Some of them probably are not going in because they have corona and sorting that out is somewhat difficult.

Intensive care admissions for breathing difficulties is another one.

The death rate, that's not so easy. Some of the deaths are definitely due to corona, others are definitely not to corona, yet some of those may have corona on a PCR test. So what do you count those patients as? And then there's ones in the middle where you just don't know if they had corona and died from it, or it just happens that they've died with corona, and died of cancer or a myocardial infarction or whatever.

And then finally, you've got recovery figures, which Britain has never published. All other countries, the majority of other countries, publish them regularly. We haven't done so for a variety of complex reasons.

Key Metrics

So, what's the key metric in all this? Well, the two key metrics are incidence and death. Incidence is perhaps more useful, because it tells you how we're going. There’s a huge lag in the deaths, especially now the main bulk of patients that have been infected have been so. So we're looking at people that have had complicated diseases, multi-system failure, renal failure, liver problems, cardiac failure, coming through the system and coming to the end, and then sadly dying.

What we're seeing now is a tail of the death curve.

But let's take the incidence because that's the key to second wave and all the other doom scenarios that could happen.

So if we look at the incidence figures, the first thing we would expect if there's a spike is for symptoms to arise. And the key symptoms we all know, shortness of breath, a dry cough, fever, and anosmia, lack of smell [and taste].

If you look at this very well curated data by NHS Digital from 111 and 999 telephony around the country, all collected every day and graphically displayed, you can see that at the peak of the pandemic, it was massive. Everybody was phoning up, getting through, or online inquiries getting through, and now it's gone right down.

Nothing happened after the demos in London and big cities. Nothing happened after the beaches were crowded with people in the first wave of the heatwave in the spring this year, and they haven't happened after the pubs opened 10 days ago.

I remember having a beer on Saturday lunchtime, looking around thinking this is, this is going to cause a bit of a blip, but it hasn't. It's now day 10, you'd expect to see a rise and there hasn't been which is really gratifying.

And in all fairness, there wasn't in Austria or the Czech Republic that came out of this 3 months ago. So this seems like good news.

Testing

So the second thing is the testing. PCR testing is all there is. Forget the antibody, that doesn't tell you information about incidence it just tells you the prevalence of immune function against the virus.

So let's look at the PCR testing. Very confusingly. There's two pillars. Pillar 1 was run by Public Health England using hospital labs for staff in hospitals. Pillar 2 was commercially outsourced to big companies such as Randox, to set up testing stations - sometimes helped by the military to run the stations - and these were very effective at picking up cases.

The problem is, is how the data were handled. And in a report out on Sky News, which is really worth the read, 'Coronavirus, the inside story of how UK’s chaotic testing regimen broke all the rules'.

It's a fascinating read. It shows that things were just made up on bits of paper to give something for ministers to say at these dreadful 5 o'clock briefings, that if you could bear to watch, if you’d got nothing better to do, were just awful.

So, I think you know, both the pillar 1 and pillar 2 have shown that now we're right down. We're less than 600 cases consistently. And hopefully we'll drop to 200 or 300 cases and it'll gradually disappear as August goes through.

Test and Trace

The real problem though, is the test and trace programme. You know, it's just not working. And despite the 'world class' scenario with or without the app tested on the Isle of Wight, shown to be completely useless, the whole system is just not working.

And the reason probably it's not working is that there's no trust in it. If I get phoned up by a contact tracer to say that yesterday I was in a bar and I had a drink, and someone within a metre of me has been tested as positive, and I should go and isolate for 14 days - would I do that?

Who was it? Who will give me the name? Let me make the assessment how close I was, because just because I was in the same room as someone doesn't mean I'm likely to be infected by them.

So it's a very difficult area for measurement and for making it sensible.

The good Baroness Dido Harding, Oxford and Harvard educated business lady, former chief executive of TalkTalk, the phone company, she was given the job. I didn't see it advertised in the BMJ.   

What one wonders is, why is someone like that able to run a very ambitious programme with no previous experience of infection control or managing expectations?

Surely there should be someone in Public Health England that could run that sort of programme very effectively.

So, as we come out of this what we're going to see are little blips, Leicester [back in lockdown], a Herefordshire Farm, these sort of things will come.

It's really important that we have transparency in the data. At the moment it's all kept hidden. The council in Hereford made a noise about it wasn't given the data, Leicester council gave the same feeling, they weren't given the NHS Public Health England data or the commercial testing data.

Complete transparency, with anonymity, of course, for the individuals involved, is absolutely vital if we're going to get this to work.

Other countries have done so much better. If we look at Singapore, Seoul in Korea, these are models of how to do it.

In Seoul, a guy goes into the nightclub district on a Saturday night heavily infected, and 700 people get infected. That was 2 months ago nearly. All sorted within 3 or 4 weeks, all gone. Everybody isolated, tested and moving on. Not a single case in that district anymore after quite a sizable outbreak because the chap went to serial bars and danced through the night singing and yelling and had a few drinks too many I suspect.

Getting Our Act Together

We've got to get our act together much better here. It's back to where I started. In oncology, we measure everything and we do it very well. And that's the secret of success in cancer medicine.

In this, the secret of success is measuring an infection rate, we need to do that. Otherwise, it could be that the doomsayers of more second waves, third waves, that more incidence and deaths, could be correct. Let's not have that. Let's measure correctly now and do it properly.

Karol Sikora. Thank you for listening.

You can follow Prof Sikora on Twitter.

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