“This business of petty inconvenience and indignity, of being kept waiting about, of having to do everything at other people’s convenience, is inherent in working-class life. A thousand influences constantly press a working man down into a passive role. He does not act, he is acted upon. He feels himself the slave of mysterious authority and has a firm conviction that ‘they’ will never allow him to do this, that, and the other.”
― George Orwell, The Road to Wigan Pier

“Disobedience, in the eyes of any one who has read history, is man’s original virtue.”

― Oscar Wilde, The Soul of Man under Socialism

Cast somewhere in the indeterminate space between a cheery travel rep and Peter Kay’s building society teller, a sketch of Liverpool’s here-to-help Director of Public Heath Matt Ashton greets you on recent Liverpool Express blog post. In the background, the skies are blue, and there appear to be some stylised palm trees planted on sand dunes, but they might also be renditions of a Liverpudlian sky mark. The imagery is of blokeish affability, and as the blog is about health matters, one expects perhaps some gentle nudging to make sure you get your five a day, or stay safe when out in the sun. Nothing could be further from the truth. The post is instead a sabre rattling blood curdling Lord Kitchener styled “…your city needs you…” appeal, to Liverpudlians. Liverpudlians, the posts says, your city needs you to get tested for covid.

The first five paragraphs set out the grim statistics and consequences for Liverpool from the pandemic, setting the stage for what is to come: a Hotel California on a Merseyside fantasy world in which you can check in any time you like, but you can never leave. For here is the UK’s first mass covid screening pilot, not imposed on Liverpool by a high handed Westminster government, but invited in by Liverpool’s city council. For good measure, the same spirit of inclusive hospitality was extended to the British Army, who were also invited in, presumably to help with the catering. 

That the pilot has more holes in it than one of Al Capone’s victims should come as no surprise, given the haste with which it has been launched. Matt Ashton, though now in Public Health, has a backstory that starts in economics, and travels through banking and the Inland Revenue, before ending up in Public Health, so it is perhaps not surprising that some of the medical niceties of mass screening have been rather glossed over. The quality of the screening test — always central to any screening programme — has only been hastily evaluated in clinical settings, in very few patients, with only the briefest of barely adequate published reports on the findings. And yet, the way Matt tells it, the test, which tests for viral antigen, can detect infectiousness, which it can’t: it’s the same old finding a broken needle in a haystack doesn’t mean you can say your haystack is a sewing machine thing, all over again.

Because the test was only briefly evaluated in quasi-clinical settings with symptomatic patients, where the prevalence of SARS-CoV-2 antigen was set high (between 25%, 75/295 from the IFU and this Chinese in English report of what appears to be the same trial, and 46% (60/131), from the mysterious unpublished Porton Down trial) , the results cannot be extrapolated to testing asymptomatic people in community settings, where the prevalence is an order of magnitude or two lower (around 2.2% in the North West, latest ONS figures). These significant differences in prevalence matter, because as prevalence falls, false positives increase, as the proportion of true negatives available to be incorrectly classified as positives rises. If you are doing mass screening, even a very small false positive rate can turn very quickly into a large number.

This flaw — over-confident deployment of a test in the field after trivial validation in small highly polarised trial — is a basic clinical error. What may happen in a  specialised setting in a lab rarely if ever translates smoothly into real world experience. The recent Manchester screening pilot, for example, used a similar rapid test, based on LAMP technology, which claimed, based on lab tests, a sensitivity ranging from 55-96% (depending on viral load) and a specificity of 100%. In the field, the test achieved a sensitivity of only 46.7%, far below its claimed sensitivity. More than half (53.3%) of all true cases were missed, potentially infectious individuals wrongly told they were not infectious.   

Liverpool’s mass screening is billed as a pilot, but as far as can be told — precious little has been published about the pilot’s protocols and procedures — the pilot is not about evaluating the clinical performance (sensitivity and specificity) of the Innova lateral flow test in use. That would require large numbers of Innova tested Liverpudlians to undergo an extra ‘gold standard’ test, the far from perfect PCR test, which isn’t happening. Instead, the pilot appears to be firstly, and most obviously, a logistical pilot: muster some soldiers and see what they can do; but it also appears to be a political pilot: can regular rapid mass testing, and all that follows from it, be made politically acceptable?

This is the point at which we get on the road to passport hell. About half way down Ashton’s post is this oblique reference to what lies further down the road: “In addition, people who test negative may be afforded more flexibility to carry on with their day to day life. We are exploring with government what this could look like”. Tie this in with Innova (IMG)’s ‘Our Story‘, and it becomes very clear what IMG’s Mr Huang and his buddies have in mind: nothing short of a health passport ecosystem; and Ashton is already ‘exploring with government what this could look like’. For a rather less benign view of ‘what this could look like’, consider this terrifying account of what is already happening in China, and that the company of ‘Infinite Possibilities’ behind the technology is already here in the UK, conveniently enough for Ashton, just down the road in Manchester.

Oppression doesn’t always arrive on the heel of a jackboot. Sometimes the oppressors seduce, by bold offers. Ashton’s post is sprinkled with just such offers: “save the lives of people you know”, “get us back to a new normal more quickly” (we’ll put aside the semantic nonsense of getting back to something new) and, perhaps most appealing of all, “a Christmas where we could do more social mixing and more of the things that we all enjoy”. But make no mistake: these offers are the appealing outer colours of a Trojan Horse that bears a payload of increased state surveillance, all implemented through a digital health passport ecosystem. Perhaps — should the state smile on you —more flexibility for those who test negative, but of course that means less flexibility for those who test positive, or ‘presumed positives’, those who refuse to be tested.    

One could go on about the flaws. For instance, there are plans to extend the mass screening to schools. Putting aside ethical questions of informed consent, how many of the parents of those pupils who test positive will self-isolate? Hatt Mancock may have just announced Liverpool style testing will be extended to 67 regions, but so far, at the latest count, only 23,170 self-selected Liverpudlians have been tested, and of those, only 0.7% tested positive, which is itself intriguing, given the current ONS prevalence estimate of 2.2% for the North West. Could the real world sensitivity of the Innova test, like the Manchester test, also be less than 50%, such that we should be gas-lighting the green-lights?

Answers may or may not forthcoming, but in the meantime we could do worse than remind ourselves of Orwell and Wilde’s words. If we extend working class to include, as many do, all those who labour for a living and are paid in wages, then large swathes of Liverpudlians face a thousand influences constantly pressing them down into a passive role, where they do not act, but are instead acted upon, by the well intentioned but ultimately malign forces of misguided authority. But there is another option: rather than obediently track along the road to passport hell, heed Wilde’s rail against the sentimental dole, which, Wilde notes, usually comes with impertinent tyranny, and recognise instead the pure virtue of disobedience. 

This article has 9 comments

  1. Annie Davenport Turner Reply

    I’ve been eagerly awaiting Dr No’s thoughts, as have those I know now following you.

    I, too, saw the 0.07% vs 2.2% and wondered about what will happen now. (If ‘wondering’ is enough any more in this evolving nightmare; one from which, it seems, we will now never wake up.)

    This, ‘More than half (53.3%) of all true cases were missed, potentially infectious individuals wrongly told they were not infectious.’ simply has me ask (with respect to all) a plain question: ‘With this having been the case for months, why are we not all dead by now?’

    The ‘asymptomatic people are walking time-bombs’ belief seems to be where discourse usually stops; old vs new science (?) and I never know what to say next.

    Another absent area in the media seems to be that undertakers are, if not struggling for business, finding numbers to be much lower than usual. What is Dr No’s take on this?

  2. Tish Farrell Reply

    Annie’s comment about why haven’t we all died yet is pertinent. For ages it’s been bugging me that all along the Government has reacted as if there was no general widespread infection prior to WHO crying pandemic. Yet the virus was abroad from at least October, and thereafter it transpired that there was regular academic and business traffic between Wuhan and the UK and other European parts (who knew?). Prof Sunetra Gupta, for one, has been contending widespread infection from at least January.

    I think I had the virus in February. It was certainly the strangest virus I’ve ever had, cycling through a weird range of symptoms. I’ve spoken to others who likewise think they succumbed between Dec and Feb. Before I took to my bed, I also had the chance to infect quite a number of friends, family and especially my husband who shared the house with days of my unstoppable coughing. No one I’d been in close (huggable) contact with became ill.

    The Gov’s HCID status for SARS CoV 2, as well as all findings from everywhere ever since March, indicate that 99% of people who catch it will only experience flu-like symptoms, or may not even notice they have been infected. So how many hundreds of thousands of us may have had the virus, got over it, and never alerted our GP surgeries because we did not get ill enough to think beyond self-medicating for flu which in my case involved numerous doses of lipsomal vit C and zinc? This is potentially a huge segment of the population.

    And does this not have some considerable significance when it comes to vaccination? If I’ve been infected, and now have immunity, why should I be coerced into being vaccinated? And does my other half have pre-existing immunity since he did not succumb? So why should he be vaccinated. Yet as we are senior citizens we will doubtless be pressured. There are so many human rights issues here. I have explained all this to my MP, but so far only lockdown supporting silence from his quarter.

  3. dr-no Reply

    Annie – remember the 53.3% was from a pilot using a LAMP test. Still pretty dreadful performance, though, and may be the real world figure for real world in- the-field testing. The mysterious unpublished Porton Down trial for Innova has just been published and suggests an overall sensitivity of 76.8%, dropping to 57.5% for self trained members of the public given a protocol. Overall specificity was 99.68%. The study is unusual in its presentation, and merits a closer look (Jon Deeks is on the case) but those are the headline figures. The take away is that rapid tests sacrifice accuracy for speed.

    The real problem is we don’t have good real world test that can reliably determine current infection (let alone infectiousness) in the general population, ie both symptomatic and asymptomatic people, so we don’t know how many people have and have had covid-19. It may be far more, or far less, than the official current figures. One intriguing question is why is the trajectory of deaths in the so called second wave, which is happening in the autumn/winter rather than the spring, so different to the first wave? One possibility – and that is all that it can be at this stage – is that many have already been infected, and so already have immunity.

    I’m not sure undertakers are less busy that usual, except for perhaps a very small dip over the summer. Figure 1 from the latest ONS weekly deaths report suggests undertakers should currently be normally busy for the time of year.

    Tish – the potential for coercive vaccination (the pressure will be social as well as potentially legal enforced) is indeed very worrying, and the current froth about the interim Pfizer results isn’t helping. GPs are already being told to cut back on normal services (will ‘health leaders’ ever learn?) so they can start running covid vaccination clinics. This isn’t running before you can walk, it’s doing a whole marathon as sprint speed while you are still in the cradle, and yes, people are going to get hurt.

  4. Tom Welsh Reply

    This excellent article brings out what is, to my mind, the most important and frightening fact of all.

    Namely, that we now live in a world where people like Matt Ashton, a generic bureaucrat with experience in “economics… banking and the Inland Revenue” are imposing medical measures on everyone; and qualified, experienced doctors like Dr No, Dr Kendrick and hundreds of others can only watch and comment.

    My first job was with a small computer company whose managing director liked to boast that a good manager could manage anything. (His previous post, I believe, involved running a sausage business).

    About a year after he made this genial remark the company went bankrupt. This impressed on me that neither generic “management” experience, nor understanding of the sausage trade, equips a person to run a computer company.

    A fortiori…

  5. dr-no Reply

    Thanks Tom. Dr No has now had a chance to review the Oxford/Porton Down (preliminary) study (linked to above) that reports the sensitivity and specificity of the Innova test. The study is unusual, some might say bizzare, in format but buried within it is the key real world sensitivity data: of 372 PCR +ves (they used the problematic PCR as the gold standard) => 214 LFD true +ves, 158 LFD false negatives

    The numbers are on the small side, but they are the best we have for now, and they give a real world sensitivity of 57.5%, 95% CI:52.3-62.6%. meaning the Innova test gives a green light (not infected) result to 4-5 of every 10 infected (by PCR test) individuals. Liverpudlians, lock up your grannies! Real world specificity was 99.61% (39 false positives in every 1000 test positives). This is the key chart from the study, with annotations (also posted on twitter):

  6. dearieme Reply

    But if you don’t have a properly proven “gold standard” what are all these comparisons worth?

    Maybe “214 LFD true +ves, 158 LFD false negatives” means that there were 214 true positives and that the PCR test was wrong about the other 158.

  7. dr-no Reply

    dearieme – very true, posted these two on twitter earlier this am (Dr No is still chiefly a blogger, but twitter gets some stuff too):

    “Agree, PCR also probably has high false +ve rate. The key point is NONE of the tests are much good. The true gold standard (viral culture) is impractical and hardly ever used in the real world, so we end up using dud tests. A case case can be made (+/- won) for binning the lot”

    “Strictly speaking neither is a test of infection (needle in haystack ≠ sewing machine problem). Key things are PCR is absurdly over sensitive, LFA is barn door (so ???better discriminator) but flip side is appalling real world sensitivity, misses 4-5 out of every 10 true +ves”

    All testing A against (gold standard) B does is tell you how A does compared to B. If B is cr*p, then the result is about as much use as cr*p. That said, there may (or may not) be some utility in using lateral flow tests to identify those with high viral loads, but the problem is we don’t really know very much about real world infectiousness eg does high viral load = highly infectious? Seems likely, but do we know for sure?

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