Ten million Covid tests a day? This “moonshot” looks off course already

The government’s grandiose gestures are no substitute for competence on the basics

September 16, 2020
Photo: Isabel Infantes/EMPICS Entertainment
Photo: Isabel Infantes/EMPICS Entertainment

If anything close to normal life is to resume in the absence of a vaccine against coronavirus—and indeed, probably even after that is available—large-scale and effective testing for infection is vital. Only then will hospital staff and care workers know if it is safe for them to go to work, and where to put new patients. Only with a secure testing strategy in place can we hope to avoid further massive disruptions in work and education, to feel safe about traveling (for example with mandatory testing at airports), and to distinguish seasonal sniffles from something potentially much worse.

All this demands not just that the capacity for Covid-19 testing be expanded way beyond what is currently available, but also that tests are cheap, reliable and fast. So an announcement by the UK government at the start of September earmarking £500m for boosting the development of on-the-spot rapid-testing technology could sound like good news. And it now seems that an eye-watering £100bn—an amount greater than half of the annual NHS budget—might be allocated for “Operation Moonshot,” a programme that could screen the entire population, conducting around 10m tests a day by early 2021 by harnessing these putative new technologies.

You might expect that these ambitious schemes would be welcomed by health officials, scientists and businesses. But neither announcement has gone down well at all. “It is hard not to feel this ‘moonshot’ has wildly missed the moon,” Alan McNally, professor of microbial genomics at the University of Birmingham, wrote in the British Medical Journal. McNally, who helped set up one of the “Lighthouse labs,” the rapidly established backbone of the national Covid-19 diagnostic testing programme, in Milton Keynes, confessed that “I find it hard to understand the logic behind the government’s new strategy.”

Behavioural scientist Stephen Reicher of the University of St Andrews, who has advised the Scientific Advisory Group on Emergencies (Sage) on the Covid-19 response, was even more blunt. “The ‘moonshot’ feels like one of those vanity projects most associated with minor dictators,” he tweeted. “It is a narcissist’s dream of grandeur and legacy. It provides something you don’t get from the unglamorous grind of doing the simple things well.” The Independent Sage group set up by former government chief scientific adviser David King called the project “a distraction” in a recent report, while one member—Allyson Pollock, co-director of the Newcastle University Centre for Excellence in Regulatory Science—branded it “pure madness and a scandalous waste of money.”

Is it churlish to criticise the government first for not testing enough and now for committing to such a vastly ambitious testing plan? Not at all. It doesn’t seem unreasonable to have doubts about the capacity to deliver for an administration that began by abandoning large-scale testing when it was most needed in the early stages of the pandemic, then distorting or massaging the figures for the number of tests it was conducting, heralding a “world-beating” contact-tracing system that didn’t work, reopening schools while many people who needed tests were told to drive hundreds of miles to a facility, and blaming the problems on people arriving (often at considerable effort) to be tested when they were allegedly “not eligible.” Add the major restructuring of the government’s public health authority in the midst of the chaos, and the confusing and illogical rules restricting public behaviour, and to trust in such a government’s ability to deliver would be reckless.

The current testing system, allegedly ready to face the challenges of the autumn, already seems close to breaking point as the number of cases rises in what looks set to be a second wave of infection. Despite overall increases in capacity, which now compare favourably with many other European countries, some people seeking tests in recent days were faced with a message on the government’s website that looked more like what you’d expect trying to order an Ocado delivery: “We are experiencing very high demand for testing at the moment. Please try again tomorrow.”

No wonder, then, that many scientists feel the money destined for these new technologies and schemes would be better invested in improving the existing ones. “Working on a rough but well-informed cost estimate of £15 per test,” wrote McNally, “the initial announcement of £500 million [for developing rapid tests] could have funded around 33 million standard swab tests.” These “could have been run in well-equipped university labs with existing experience and expertise,” he argued, “while widening the network of mobile and walk-through test centres feeding into these satellite labs.”

McNally thinks the government should have been strengthening and expanding its existing testing programme back in the summer, after Covid-19 had finally become relatively contained, to include wider surveillance and community-testing pilot projects in preparation for the expected resurgence in the winter. This, he wrote, “would have left plenty of time to deliver a coherent community testing and surveillance strategy as schools, universities, colleges and businesses returned to action.”

“I personally suggested this to the Department for Health and Social Care and the wider Lighthouse management structure,” he continued, “but it appeared to fall on deaf ears.” The consequences of that lack of preparation are now becoming painfully apparent.

The concerns that have been voiced about Operation Moonshot from leading scientists and health experts stem also from the fact that it relies on technologies that either do not exist at all or have not yet been validated, let alone manufactured at scale. It is, in other words, a massive gamble on science’s capacity to deliver.

What’s more, the shambolic way the project has been set up and announced gives no grounds for confidence. Because it seems intent on mass-testing large sections of the population, including asymptomatic people deemed to be “at moderate risk,” it is really a kind of national screening programme. Yet the National Screening Committee, which advises the government and the NHS about population screening, has not been consulted. Pollock told the Guardian that this was “incomprehensible,” and others have warned that input from the committee or other experts is essential. It remains unclear too whether Sage will endorse the project. It has previously warned of the tremendous logistical challenges of mass screening and the dangers of introducing “immunity passports” for people to attend events, and has questioned whether such a programme would really offer more benefit than investing the same resources in improving the existing NHS test-and-trace system.

One big concern about mass testing is that it inevitably produces more false negatives and false positives: people who are told they don’t have the virus when in fact they do, and vice versa. Short of improving the reliability of the testing methods (and also reducing the scope for errors in processing and transmitting the information), there’s no easy fix for that—but it requires careful, expert handling to minimise the risk of large numbers (perhaps millions) having to self-isolate when they don’t need to. So sidelining the National Screening Committee seems foolhardy.

In short, even if the principle of this "moonshot" has some merit, its timing (as the extant testing facilities fall into disarray) and execution so far offer yet another example of how the government seems almost wilfully determined to alienate scientific and health experts with its lack of consultation, ministerial blunders and nationalistic posturing.

Photo: Jonathan Brady/PA Wire/PA Images Photo: Jonathan Brady/PA Wire/PA Images

Is "Operation Moonshot" a classic Cummings-style project? Photo: Jonathan Brady/PA Wire/PA Images

Given all the political hubris and strategic problems, what then is the case for the defence? In terms of the sheer technological challenge, while the "moonshot" scheme like this is very ambitious, it is not absurdly so.

Indeed, the technical innovation on testing (as well as vaccines) that is happening in the UK is encouraging. The method on which Operation Moonshot seems to depend—which delivers results within close to an hour from saliva rather than nose or throat swabs—has just begun a Phase 2 trial (which looks for efficacy in modest-sized sample groups) at four schools in Southampton. Already involving more than 2,000 pupils, the trial is soon due to expand elsewhere in Hampshire. It relies on a technique called LamPORE, developed by the British company Oxford Nanopore, which first “amplifies” DNA in the sample to make it possible to spot the presence of the coronavirus genome and then reads the DNA sequences rapidly by pulling the molecular strands through tiny “nanopores.” It’s fast (although currently the testing time is more like 90 minutes than the 20 minutes hoped for), cheap and portable.

Another fast test that can be done on the spot, developed by the company DnaNudge, is being trialed in London hospitals. Other rapid tests are being studied elsewhere in the world. “Even if one technology doesn’t work out for rapid on-site screening, we have others in the pipeline,” says geneticist Andrew Beggs, who leads testing efforts at the University of Birmingham.

Beggs’s team has also shown that the daunting volume of tests proposed for Operation Moonshot might be reduced by “household pooling,” where everyone spits into the same tube and each household is tested, say, once a week. Further pooling is then possible in regions of low prevalence, and if done in an overlapping manner then statistical algorithms can figure out which individual tests in a sample are positive. Beggs says that pooling 12 tests into one, producing around two million samples per week to analyse, could work very well at a regional level.

He adds that, given that so many schools, workplaces and so on are shutting because of delays in testing, in theory a mass testing approach with a 1 per cent false positive rate is still better than nothing. “We are never going to have a ‘perfect’ test,” he says, “but we should be aiming for ‘good enough.’”

Even that, however, remains a matter of hope until all the clinical trials have been conducted. Even if they work out, there’s no guarantee that the methods will deliver on schedule.

It is also important to remember that tests are only effective if their results are acted on. This means that people who test positive must self-isolate properly—which some will surely not if they can’t afford the hit to their earnings. An Independent Sage report stated that there is “increasing evidence that only a low proportion of those asked to isolate for 14 days are able to do so”—not surprising, perhaps, given the derisory financial compensation offered by the government for those who would lose income by self-isolating. What’s more, testing needs to be accompanied by good contact tracing, and here Britain is not performing at all well.

In other words, some of the likely problems are not technical but socioeconomic—a reminder that, as Shobita Parthasarathy, professor of public policy at the University of Michigan, has written in Nature, “we can’t just tech our way out of the pandemic.” The social inequalities that the virus has exposed (and sometimes worsened) need to be addressed urgently. Chris Hopson, chief executive of NHS Providers, tells me that contact tracing has proved particularly challenging among some communities, such as those where English is not a first language or where high numbers of people tend to shun interactions with the state. They need targeted trust-building: contact tracing must not seem “just a white middle-class operation,” Hopson says.

Trust, indeed, underpins so much of this: trust that tests are safe and reliable (this will be a massive issue when Covid-19 vaccines are available), that the rules on behaviour are reasonable and apply to all, and that public health and not private gain is being prioritised. This is perhaps the government’s biggest problem of all, for it does not so much fail to build public trust as systematically undermine it. That was clear in the wake of Dominic Cummings’s Durham escapade, when studies showed that public trust in the government plummeted. People’s willingness to give contact information for test-and-trace measures “is less likely when they don’t trust the government,” says Reicher.

Operation Moonshot looks all too much like yet more performative governance: a grandiose gesture to distract from the shortcomings of the existing systems. The generous view is that we should give it a chance, and that despite all the U-turns and gaffes, the government has some sound expert opinion and technological potential to build on. But even if the principle has some merit, Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine, has said that the plans bear the hallmark of a government “whose ambition far exceeds its ability to deliver.”

Yet this is precisely the kind of ambitious project that Cummings has made no secret of regarding as the future: high-profile, Apollo-style schemes that are fuelled by and generate big data, supported with bottomless pockets, and that hinge on innovative scientific and technical thinking. In some ways, it’s the kind of thing some scientists dream of. Unfortunately, the implementation so far seems also to bear Cummings’s trademark arrogance: imposed by diktat without asking the right experts (indeed with apparent disdain for that expertise), and launched amidst hype and rhetoric but without a sound and transparent explanation of how the scientific, technical and logistical challenges will be met. It looks worryingly like the vanity project of someone who considers it too boring simply to do the essential basics well.

Operation Moonshot could be a chance to prove the critics wrong. If it succeeds, the effect could be transformative. But the stakes are extremely high, and already the signs are far from auspicious.