SMART testing for COVID-19

The University of Liverpool responded to a call from Liverpool City Council and Government in October 2020 for urgent research into the feasibility of large-scale Covid-19 risk-mitigation with rapid antigen testing.

An agile, intelligence-led response was possible through building on the existing partnership between with the University, the local authority and public health teams that had formed the Combined Intelligence for Population Health Action (CIPHA) platform. CIPHA was conceived pre-pandemic in planning the UK’s first Civic Data Cooperative, supported by Liverpool City Region Combined Authority, and its success has been recognised in the 2021 Bionow awards as Healthcare Project of the Year.

The University of Liverpool, Liverpool City Council, NHS Test & Trace, NHS Liverpool Clinical Commissioning Group and Cheshire & Merseyside Health & Care Partnership established a repeated testing scheme that focussed on asymptomatic cases (testing people who displayed no COVID-19 symptoms) with the aim of providing evidence of how to deliver testing within wider measures to reduce and contain transmission of the virus.

Professor Marta García-Fiñana from the Institute of Population Health said “This work has directly benefited from the CIPHA integrated care record system combined with Liverpool expertise in health data analytics, data modelling, qualitative social research, public health medicine and infection. It is a great example where different partners speedily formed a well-integrated multidisciplinary team to successfully tackle urgent population heath challenges”, and she praised “the enthusiasm and fantastic team spirit, especially given that most of this research was conducted during very challenging times.”

From the University of Liverpool, involved in the project were Professor Iain Buchan, Professor Marta García-Fiñana, Professor Calum Semple, Dr Mark Green, Dr David Hughes, Professor Benjamin Barr, Professor Rhiannon Corcoran, Dr Chris Cheyenne, Dr Girvan Burnside, Professor Sally Sheard, Dr Nina Zhang, Dr Dimitrios Charalampopoulos and Professor Kay O’Halloran.

Challenge

One of the key challenges was how to reduce transmission and protect populations whilst also tackling the harm to health and social and economic wellbeing from severe restrictions such as lockdowns. Being able to relax restrictions whilst keeping the spread of the virus minimised is key to societal recovery from pandemic emergencies like COVID-19.

For the Liverpool COVID-SMART project, the objectives were to generate understanding of:

• How offering large-scale testing would be received by the local community
• How lateral flow testing would perform in large-scale asymptomatic testing
• Whether large-scale testing would help to contain the pandemic, reduce adverse health outcomes, such as hospital admissions, and support social and economic functions.

Solutions

In the space of a week, this local service & science partnership used emergency planning alongside the British Army to begin offering asymptomatic testing for all people living or working in the city of Liverpool.

The scheme successfully created an opportunity for voluntary, open-access community rapid antigen testing that provided real-world evidence of how to deliver testing within wider public health measures. This included clarifying the science around lateral flow testing performance and translating this from the usual clinical diagnostic context to the more relevant and complex public health setting where testing behaviours and social contexts are just as important as test accuracy. The Liverpool team highlighted important inequalities, not only by socio-economic groups but also by digital poverty, and the importance of equitable support to isolate.

Professor Buchan said “Liverpool grit has driven public health innovation for over 170 years, and in 2020, that spirit was palpable as the COVID-19 pandemic hit the most disadvantaged communities hardest. I was humbled and inspired by the extraordinary teamwork that delivered much needed policy evidence from COVID-SMART under considerable pressure – especially by the unfailing participation of the people of Liverpool.”

Impacts

By mid-December case detection had risen by a fifth, and compared with other areas using synthetic control methodology, cases were a fifth lower in Liverpool and hospitalisation almost halved. Liverpool’s economy and social fabric had restrictions lifted in December 2020 when all surrounding areas were effectively closed. The pilot was extended to the wider Liverpool City Region on 3 December and over the following month the region saw around a third less Covid-19 hospitalisation versus a synthetic control. In addition to the reduction in cases, daily lateral flow tests were used as an alternative to quarantine for key workers who had contact with an infected person. This meant that essentially services were maintained, saving 8,292 key worker days and supporting public safety.

The pilot delivered world-leading evidence on COVID-19 testing. Research teams provided reports to the Scientific Advisory Group on Emergencies (SAGE) in November and December of 2020 as soon as sufficient data were gathered. The University delivered further reports for government in January, July, and December 2021. Open-access rapid antigen community testing became the national policy. Repeated dissemination of findings on inequalities in testing uptake eventually influenced policies on isolation payments. Various reports and papers are cited in national COVID-19 testing policies in the UK and around the world.

Follow-on impacts

The following April/May, Liverpool’s COVID-19 testing and award-winning health data platform CIPHA enabled it to reopen the first live music events in the Northern Hemisphere, with only 12 linked cases among >13,000 eventgoers. This was the only part of the UK’s Events Research Programme that achieved linked ticketing and testing data driving contact tracing. Similar systems are now in place for international events and recommended by WHO Mass Gatherings unit. In addition, CIPHA is now sustained as an NHS England programme.

Professor Calum Semple, from the University’s Institute of Infection, Veterinary and Ecological Sciences, said “Once again the civic partnership between the city of Liverpool and the University provided the science for policy makers to follow. We showed how equitable local access to rapid testing reduced hospital admissions by half and allowed large events to be conducted without amplifying cases of infection. As a result, Liverpool was the only city to come out of lockdown to a lower tier of restrictions, allowing our economy to open up quicker and people to enjoy the company of others in safe settings, bring much need joy to our hard pressed communities”

As a novel partnership of science and society, the scheme has impact across the world, and demonstrated how important knowledge exchange and collaboration is for tackling key global issues. It delivered action research and provided important evidence for urgent public health policies and tactics, especially in guidance for how to make the most of the rapid testing times lateral flow tests allow and the need for support for those who are isolating with low incomes.

The pilot scheme also created an opportunity for researchers to become more involved in the public health ecosystem, likely creating more opportunities for knowledge exchange and collaboration in the future. COVID-SMART provided an opportunity to engage with the people of Liverpool and the policy-makers within Liverpool City Region and beyond to implement a communication plan which challenged the spread of misinformation through scientific broadcasts and social media.

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