Covid-SMART rapid antigen community testing evaluations

A team of experts led by the University of Liverpool evaluated the world’s first city-wide, voluntary Covid-19 rapid antigen testing pilot in Liverpool from November 2020, followed by early roll-out across the wider Liverpool City Region in December 2020 of the national Covid-19 community testing scheme.

Community testing review, November 2024

To mark four years since Liverpool led the first mass community testing scheme for Covid-19, The Pandemic Institute has collaborated with Professor Iain Buchan to produce a short film exploring the city’s response, and how we can use data-driven community testing in future pandemics.

You can find full details of the review here.

Latest analysis, November 2022

The latest analysis complementing the wider evaluation found that the city’s Covid-SMART pilot was associated with an overall 25% reduction in covid-19 related hospital admissions, including a 43% reduction in the pilot’s first month.

Researchers say that, if causal, the effects of the pilot prevented 6,829 infections and led to 239 fewer hospital admissions across the city of Liverpool, before being rolled out to the rest of the UK. Read the full news story.

Watch Professor Iain Buchan discuss the latest analysis:

Quantitative evaluation, Liverpool City Region community testing roll out

The analysis of Liverpool City Region’s Covid-SMART community testing initiative (December 2020 – July 2021) revealed insights that helped policymakers, public health teams and the public with community approaches to Covid-19 testing.

The Liverpool City Region Covid SMART evaluation (PDF, 8MB), led by researchers from the University of Liverpool’s Institute of Population Health, identified:

A 32% reduction in Covid-19 hospitalisations – a larger effect than previously reported from synthetic control analysis following release of more detailed national data
The ‘test to release’ scheme saved 8,292 key worker workdays. Workers used a daily negative lateral flow test (LFT) as a Covid-19 certification to work. 34 Covid-19 cases were identified - only three of these had been missed by daily LFTs
Test-to-release (also known as daily contact testing) is important for civic resilience – evidence needs to inform current and locally variable policies.

Liverpool Covid-SMART pilot evaluation

Download the full report here: Liverpool mass testing evaluation (PDF, 8MB).

Watch: Professor Iain Buchan discusses the evaluation

The pilot

On 6 November 2020, Liverpool City Council, NHS Test and Trace, NHS Liverpool Clinical Commissioning Group, Cheshire & Merseyside Health & Care Partnership and the University of Liverpool embarked on a national pilot of community open-access testing for the Covid-19 virus – available to people without symptoms in addition to testing services for those with symptoms. Testing was available to everyone living or working in the City of Liverpool.

The purpose of the pilot was to reduce or contain transmission of the virus while tackling the mounting harms to health, social and economic wellbeing from Covid-19 restrictions.

The report

This is the full report from an evaluation led by the University of Liverpool into the Liverpool COVID-19 community testing pilot. The evaluation was invited by the joint local and national command of the pilot and sponsored by the Department of Health and Social Care (DHSC).

This report extends an Interim Evaluation published on the University of Liverpool website on 23 December 2020 and summarised on GOV.UK on 14 January 2021.

The report evaluates the data on the biological, behavioural and systems aspects of the pilot and its early public health impacts. It presents findings to help policymakers with community approaches to COVID-19 testing.

The report was led by the University of Liverpool, alongside researchers from NHS Test and Trace, Joint Biosecurity Centre, Public Health England, and Office for National Statistics.

Main findings

The pilot team developed a SMART (systematic, meaningful, asymptomatic and agile, repeated testing) approach. The targets were:

Test-to-protect (vulnerable individuals, settings and services)
Test-to-release (sooner from quarantine, when appropriate and combined with other measures)
Test-to-enable (safer return to key activities for social fabric and the economy, when appropriate and combined with other measures).

The evaluation found that a low-cost, rapid, no-lab test of likely infectiousness saves time and extends the reach of health protection measures. The data showed that lateral flow rapid antigen testing meets this need when coordinated by an effective local public health service.

The end-to-end testing service was found valuable and has been continued beyond the pilot as a core part of Liverpool’s Covid-19 response.

More than half of the population took up asymptomatic testing but socio-economic inequalities were a challenge

Between 6 November 2020 and 30 April 2021, 283,338 (57%) Liverpool residents took a test using the Innova SARS-CoV-2 antigen rapid lateral flow test (LFT). Of these, 47% had more than one test (27% of residents). In the same period, 152,609 residents took a polymerase chain reaction (PCR) test either because they had symptoms or to confirm a positive asymptomatic LFT result.

6,300 individuals declaring no symptoms tested positive by LFT (case positivity 2.1%)
22,567 individuals declaring symptoms tested positive by PCR (case positivity 14.8%).

Socio-economic inequalities were a substantial challenge. Test uptake was lower and infection rates were higher in deprived areas, in areas with fewer digital resources or lower digital literacy, and among non-white ethnic groups. Fear of income loss from self-isolation was a key barrier to testing.

The pilot led to an estimated 21% reduction in cases up to mid-December

The estimated impacts (with 95% confidence intervals) of Liverpool’s community testing compared with other areas were:

18% (7% to 29%) increase in case detection versus control areas
21% (12% to 27%) reduction in cases up to mid-December 2020 (after which the Kent variant surge made it difficult to compare areas) versus control areas
Pessimistic model suggests 850 (500 to 1,350) infections were prevented
Optimistic model suggests 6,600 (4,840 to 9,070) infections were prevented
Small but non-significant reduction in hospital admissions.

Lateral flow tests worked as expected

The Innova lateral flow device used in the pilot performed as expected, identifying most COVID-19 cases without classical symptoms but with high viral load – those likely to be the most infectious.

Civic pride, local co-ordination of services and effective information sharing contributed to the success of the pilot

There was strong public awareness of, and a largely positive attitude toward community testing, motivated by shared identity, civic pride and a wish to protect others. Misinformation, particularly over test performance, was a substantial problem needing intensive local communications to address.

Multiple national testing initiatives in different contexts from care homes to schools and workplaces made communication too complex and would have been better integrated into a community testing with integrated support from the local authority. The CIPHA (Combined Intelligence for Population Health Action) integrated data and shared analytics system was essential for coordinating actions between local partners. The role of the director of public health was vital to effective coordination of services and engaging the public.