this week GP NUMBERS page 254 • BREAST SCREENING page 256 • MEDICAL SCHOOLS page 258 JONATHAN KLEIN/GETTY IMAGES JONATHAN MPs take legal action over PPE contracts

Three MPs and the Good Law Project clear, mandatory, and unconditional Cross party MPs are have launched legal action against the legal obligations to publish details of its demanding the government government over what they allege is a spending.” defend the lack of published “persistent and unlawful” failure to disclose In a pre-action protocol letter sent on PPE contracts to a court details of huge sums of money spent on 23 August to the health secretary and the contracts for personal protective equipment. Cabinet Offi ce minister, the claimants The government has approved £15bn refer to data from Tussell showing that the for procuring PPE since the start of the government has published contract award pandemic. But fi gures compiled by the notices in relation to covid-19 contracts data provider Tussell show that details of on average after some 47 days, whereas only £2.68bn of that spending have been for non-covid contracts the average is 29 made public, while further analysis shows days. They also argue that publication of persistent breaches of the requirement to the covid-19 contracts, many of which were LATEST ONLINE publish information within 30 days. The awarded without a competitive tendering claimants argue the government is in breach process, seems not to be occurring routinely. US drug agency of legal regulations requiring it to publish Lucas said, “The lack of transparency may fi ne clinical all contract award notices and government and potential misuse of tens of millions trial sponsors that policy requiring that all contracts with a of pounds urgently needs investigating, don’t report data value of more than £10 000 be published in particularly as we have spent far more on Health worker full within 30 days of being awarded. PPE than any other European country.” strikes, limited The action has been fi led by the Green Abrahams added, “The government’s testing, and clinic closures hamper Party MP Caroline Lucas, Labour’s Debbie failure to comply with its legal obligation is Zimbabwe’s covid Abrahams, Lib Dem Layla Moran, and the due to either incompetence or dishonesty. response Good Law Project, a not-for-profi t company Ministers may try to argue the emergency Covid-19: 70% that uses the law to protect the interests of meant they could award contracts without of infected the public. , director of going through the competitive tender health workers the project, said, “Vast amounts of public procedure, but this does not exempt them in Victoria, money—billions and billions—are being from their duty to publish the contracts.” Australia, acquired rushed out the door. And yet what we can Gareth Iacobucci , The BMJ virus at work see is that the government is simply ignoring Cite this as: BMJ 2020;370:m3333 the bmj | 5 September 2020 253 SEVEN DAYS IN GP numbers in England fell by more than 600 in past year, data show The BMA has called for more support for GPs ahead of a potential second wave of covid-19, aft er fi gures showed a fall in the number of full time equivalent (FTE) GPs in the past year. Data published by NHS Digital on 27 August showed that in the year to June the number of fully qualifi ed FTE GPs fell by 2.3%, from 28 256 to 27 605. Richard Vautrey, chair of the BMA’s General Practitioners Committee, said that the continuing decline in the number of GPs in England was of serious concern but not a surprise. “Before covid-19, GPs were contending with chronic underfunding, rising patient demand, and toppling workloads, all of which has been exacerbated by the virus, with many surgeries going above the call of duty to keep patients safe,” he said. “And yet, despite the clear need to do more to attract and retain GPs, the government have just undermined morale further by failing to use the DDRB [Doctors’ and Dentists’ Review Body] recommendations to recognise the incredible work GPs and their teams have done during the pandemic.” Vautrey added it was important for the government to ensure that GPs had the resources needed to keep patients safe and well during the expected second wave of covid-19.

Abi Rimmer , The BMJ Cite this as: BMJ 2020;370:m3366

Covid-19 people in England, and the ONS essential healthcare in its independent Africa Regional Government will expand will also extend the survey to existing programmes worldwide, Certification Commission after trained vaccine workforce Scotland, Wales, and Northern including interventions in Italy, four years without a case. Nigeria The government will expand Ireland. The survey started as Spain, Belgium, and France. was the last African country to the trained workforce who can a pilot in May to track infection be declared free from wild polio. administer covid-19 and flu rates outside of hospitals and High risk areas get Afghanistan and Pakistan are vaccines to boost access, as part care homes, regardless of payments for self-isolating now the only two countries that of a raft of measures designed whether a person has symptoms. The government will offer a continue to see wild poliovirus to facilitate the safe future mass payment for people with low transmission. Tedros Adhanom roll-out of a covid-19 vaccine. The “Alarming conditions” in incomes in areas with high rates Ghebreyesus, WHO director government said that it would European care homes of covid-19 who need to self- general, said, “Ending wild clarify the scope of protection isolate and cannot work from poliovirus in Africa is one of from civil liability among the home. Eligible people who test the greatest public health additional workforce who positive for covid will receive achievements of our time.” could be allowed to administer £130 for a 10 day period of self- vaccinations. It also pledged to isolation. Other members of their Medicinal cannabis reinforce safeguards to support household who have to self- Parents can challenge the Medicines and Healthcare isolate for 14 days will be entitled NICE guidance in court Products Regulatory Agency to to £182. Non-household contacts The parents of a 3 year old boy grant temporary authorisation for who are advised to self-isolate with severe epilepsy were given the use of a new covid-19 vaccine, A report on the global response through NHS Test and Trace will permission to mount a landmark provided it meets the highest to coronavirus outbreaks also be entitled to as much as High Court challenge to guidance safety and quality standards. heavily criticised “alarming £182, depending on the length of from the National Institute for living conditions” in Belgian their isolation. The scheme will be Health and Care Excellence England will test and Spanish care homes, the trialled in Blackburn with Darwen, regarding cannabis prescribing 150 000 every two weeks former being described as a “true Pendle, and Oldham. on the NHS. Matt and Alison The Office for National Statistics humanitarian crisis.” The report Hughes argue that the will expand its infection survey by Médecins Sans Frontières Infectious disease guidance is so restrictive to 150 000 people a fortnight documented the first phase of Africa is declared that it could effectively in England by October, up from the organisation’s global covid- free of wild polio be barring hundreds of 28 000 now, to provide more 19 response from March to May. In a milestone children from accessing information about the spread of During that time it had committed announcement, the cannabis treatment covid-19 in the community and to “substantial resources” both Africa was they need on the NHS. The help identify local outbreaks. The to developing dedicated covid- declared free of family has legal aid for aim is to eventually enrol 400 000 19 projects and to maintaining wild polio by the the judicial review case.

254 5 September 2020 | the bmj SIXTY SECONDS MEDICINE ON . . . International news MANAGEMENT US approves emergency CONSULTANTS use of convalescent plasma The US Food and Drug WHAT HAVE THEY DONE NOW? Administration approved They’ve only gone and snared themselves convalescent plasma for another huge government contract. emergency use in hospital YOU SURPRISE ME. TELL ME MORE patients who have covid-19, It emerged last week that McKinsey & Co after it concluded that plasma was paid a whopping £563 400 for six from recovered patients “may be Potential benefits from weeks’ work to decide the “vision, purpose, effective” in treating the virus and using recovered covid patients’ and narrative” of England’s new public plasma outweigh the risks, says the FDA that the “potential benefits of the health body, the National Institute for product outweigh the known and Health Protection. potential risks.” The move came Northern Ireland in January and NICE WORK IF YOU CAN GET IT despite the absence of results February. Almost 60% said they OBESITY Indeed. And the likes of McKinsey, Deloitte, from randomised controlled wanted to be more involved in More ambitious and PwC have been getting plenty of it during trials. To date, only a preprint research. Time was the biggest the pandemic. Whether it’s for building paper on the effects on covid-19 obstacle to more participation action to help testing capacity, fi nancial advice, or strategic inpatients has been published. (cited by 53%), followed by reduce childhood vision, the government seems to have them Experts warned that there was not funding, a perceived lack of skills, obesity to 1980s on speed dial. enough evidence to show that the and a lack of supportive culture at levels would BUT THIS IS DOWN TO COVID, RIGHT? treatment worked. respondents’ organisations. save the NHS Not really. The BMJ revealed last year that the government’s spending on management Diversity Learning disabilities consultants in the NHS had trebled during Project tackles skin tones NHS leaders call for action £66bn and would 2016-19. This was despite pledges by in medical education on stigma and funding successive health secretaries to curb An NHS Providers report called for be worth spending on them. But it seems that, no immediate action to tackle stigma matter how much they really want to stop and underfunding in services for £359bn using them, they just can’t. people with learning disabilities to the wider and autism. The group, which LIKE AN UNHEALTHY DRUG? economy over the It’s certainly not very healthy for the public represents NHS trusts, identified lifetimes of the purse. A 2018 study by researchers at a “longstanding inequity in the Warwick Business School concluded that development, commissioning, current cohort of children consultancy spending not only represented A collaborative project has been and delivery of services,” which poor value for money but was also associated launched to tackle the lack of it said had harmed the health [Institute for with greater ineffi ciency. skin tone diversity in paediatric and wellbeing of vulnerable Public Policy medical education images. The people, resulting in reduced life SO, WHY KEEP USING THEM? Skin Deep initiative is led by expectancy and an increased risk Research ] Perhaps there’s an ingrained mindset of Don’t Forget the Bubbles, an of abuse in extreme cases. “private good, public bad” in the corridors international medical education of power. Choosing the private company team, and the Royal London Maternity care Serco to carry out contact tracing rather than entrusting this to local public teams is Hospital. It aims to develop a “Dysfunctional” working at another recent example that springs to mind. free, open access bank of high Essex hospital led to risks quality photographs of conditions Basildon University Hospital’s CAN I HEAR A DOOR REVOLVING? featuring a range of skin tones. maternity services have been Ministers have faced a lot of criticism rated inadequate and have recently for the number of government Minority doctors struggle been given a formal warning contracts awarded to companies they for research involvement after a surprise inspection by have links to. The fact that the new A survey from the Royal College of the Care Quality Commission. A agency will be run by the Conservative Physicians reported inequalities whistleblower alerted the CQC to peer Dido Harding—a former in access to research among six serious incidents in March and McKinsey consultant and the head doctors from minority ethnic April, in which babies were born of England’s Test and Trace programme—is unlikely to reduce accusations of cronyism. backgrounds, women, and those in poor condition and transferred working in rural areas. The RCP for cooling therapy. surveyed 1137 members and Gareth Iacobucci, The BMJ fellows in England, Wales, and Cite this as: BMJ 2020;370:m3373 Cite this as: BMJ 2020;370:m3310

the bmj | 5 September 2020 255 Johnson to Extended b reast cancer screening meet families bereaved by trial won’t resume randomisation covid-19 EXCLUSIVE Experts question whether covid is the real cause of the cessation

Boris Johnson has said he will major UK breast cancer government records will continue meet bereaved families who have screening trial that was “throughout the 2020s and beyond.” lost loved ones to covid-19. set up to determine The announcement was welcomed In what seemed a U turn, the whether extending the by those who had criticised the trial prime minister, speaking to Sky A age range to include for a lack of explicit and fully informed News on 26 August, said he would women aged 47-49 and 71-73 consent and for its study design. also reply to families’ letters. would cut mortality will not restart Susan Bewley, emeritus professor Layla Moran, Liberal randomisation after the pandemic. of obstetrics and women’s health at Susan Bewley of Democrat MP and chair of the King’s College The trial randomised women in King’s College London, told The BMJ , all party parliamentary group London asks who England so that half would receive “Although covid will be credited with on coronavirus, had written to approved the a screening invitation outside the ending AgeX, this trial would not Johnson on 24 August urging him original study normal age bracket (50-70 years). have stopped prematurely with no to meet the families. The trial was halted alongside other fanfare were it actually answering a screening services to allow the necessary research question that had “Prolonged grief” NHS to cope with covid-19, but the been through proper channels of peer “The APPG was shocked to learn researchers have announced that review and funding.” that, despite numerous attempts, randomisation will not resume. Writing in The BMJ in April 2019, you have so far refused to meet However, they said that follow-up Bewley, the medical writer Mitzi with bereaved families or show by electronic linkage to routine Blennerhassett, and the freelance any willingness to listen to their pleas,” Moran wrote. “Because of the loss they have suffered, New NIHP “threatens h ealth improvement” combined with isolation, many are now dealing with prolonged grief The abolition of Public It is a false choice to neglect and the system should be and [are] in need of mental health Health England risks health vital health improvement driven by its ability to secure support tailored to them.” improvement being neglected measures to fight covid-19 this,” it said. Responding to a question about in the next phase of the Rapid response signatories In a rapid response to The letters from families, Johnson said response to covid-19, public BMJ, representatives from he was not aware of them and health experts have warned. 2021, with a primary focus on fi ve of the 70 organisations that he would meet the families. In a joint statement sent this public health protection and that supported the statement “I am not aware of those letters, week to the prime minister, infectious disease capability. outlined their concerns. “The but of course we will write back to health secretary, and interim But in their statement the communities hit hardest by every letter we get,” Johnson said. leaders of PHE, more than 70 organisations, which include covid-19 are those suff ering “And of course I will meet the . . . health organisations said that the Association of Directors of most from inequalities in health bereaved, of course I will do that.” health improvement measures Public Health and the Faculty and wellbeing,” they said. “It Moran’s letter said the were essential to a successful of Public Health, said the is a false choice to neglect vital parliamentary group also response to the pandemic, reorganisation paid insuffi cient health improvement measures, recommended that Johnson given the evidence that the attention to PHE’s health such as those that target commit to a judge led public disease hits people in the improvement functions. smoking, obesity, alcohol, and inquiry into the handling of the poorest health the hardest. “Reorganisation risks mental health, in order to fi ght pandemic. It also asked him to The statement was issued in fragmentation across diff erent covid-19.” formally recognise people living response to the announcement risk factors and between Maggie Rae, president of with long term covid symptoms that PHE will be abolished health protection and health the Faculty of Public Health and to set up a working group to and replaced with an improvement,” it said. and a signatory of the rapid establish patients’ needs. agency that will As well as having funding response, said, “Ensuring there Abi Rimmer, The BMJ prioritise preparation to improve population is adequate funding, a robust Cite this as: BMJ 2020;370:m3356 for pandemics. health, the institute must infrastructure, and suffi cient The National be accountable for reducing public health expertise to MPs recommend the Institute for Health health inequalities, the deliver at national, regional, prime minister sets up a Protection will statement said. “Good health is and local level is fundamental.” judge led inquiry formally operate necessary to level up our most Abi Rimmer, The BMJ Layla Moran from spring disadvantaged communities Cite this as: BMJ 2020;370:m3382

256 5 September 2020 | the bmj editor Mandy Payne said that women breast screening throughout the UK only learnt of their inclusion in the in March 2020 due to COVID, and the trial through a letter with a prebooked substantial and prolonged overload screening appointment. They also on breast screening services to be argued that women were not being expected when screening restarts, the properly informed of the risks and AgeX investigators decided in May that the trial “did not meet standards 2020 that further randomisation into for generating evidence that would be AgeX should cease permanently.” robust enough to inform future policy.” In a statement issued in May the trial team said that a total of 4.4 million AgeX women had been randomly allocated The Nationwide Randomised Trial of to be sent or not sent one additional Extending the NHS Breast Screening screening invitation. “Although the Age Range was started by Public intent had been to continue until about Health England in June 2009. It aimed six million had been recruited, 4.4 to include 1.1 million women aged million will, with suffi ciently long-term over 13 years to compare breast cancer follow-up, suffi ce,” it said. incidence and mortality between The trial’s principal investigator, screened and unscreened participants. Julietta Patnick, confi rmed to The In 2016 it was renamed AgeX and BMJ that the trial had stopped the recruitment target was raised to randomisation. “at least six million.” The trial received Bewley called for an independent ethical approval in 2010 and 2016 inquiry into the study, saying, “We “ALTHOUGH the intent had been from Ealing and West London (now need to ask: who approved this, and to continue until about six million had been Harrow) Research Ethics Committee. how much did it cost?” The AgeX website now says, Elisabeth Mahase, The BMJ recruited, 4.4 million will, with sufficiently “Following the suspension of routine Cite this as: BMJ 2020;370:m3337 long-term follow-up, suffice” AgeX trial team Hong Kong scientists report first case of covid reinfection

A 33 year old man from tested positive and had not be too surprising. It Hong Kong is reported to quite a high viral load.” is, however, important have the first confirmed A press release from that this is documented. case of covid reinfection. the team said a total of Commentators have been Researchers from the 24 nucleotides differed saying for some time that University of Hong Kong’s Li between the viruses immunity is unlikely to be Ka Shing Faculty of Medicine from the first and second permanent and may only Department of Microbiology episode. Amino acid last a few months. found that the patient’s two HE WAS “When he was differences were found in “Given the different episodes were caused by ASYMPTOMATIC hospitalised days later he nine proteins, including a intensity of the antibody virus strains with different BUT STILL was asymptomatic—all 58 amino acid truncation response in people with genome sequences. TESTED confirmed positive cases in of ORF8 protein that was mild or severe illness and Their findings have not POSITIVE Hong Kong are hospitalised present only in the virus the subsequent decay in AND HAD yet been published but were for observation, from the first infection. levels, it is likely that those QUITE A HIGH accepted for publication in symptomatic treatment, The findings suggest that with a mild illness will VIRAL LOAD Clinical Infectious Diseases and prevention of onward acquired immunity after have a shorter duration of on 24 August. Ivan Fan-Ngai transmission. He remained natural infection may be immunity than those with “The man first acquired Hung in hospital for three weeks short lived. severe illness.” this infection in March, until he tested negative “Vaccination should still Brendan Wren, professor locally, probably from a twice,” Hung added. be considered for those with of microbial pathogenesis colleague who travelled “After that, he was well previous infection,” said at the London School from London to work with until four and a half months Hung. He noted that the of Hygiene and Tropical him. At that time he had later, when he came back vaccines being developed Medicine, said, “This is very mild symptoms and to Hong Kong having been were “pretty safe from this a very rare example of tested positive,” said Ivan in Spain for a week, and kind of mutation.” reinfection, and it should Fan-Ngai Hung, research he was tested on return, Paul Hunter, professor in not negate the global drive team member and clinical because everyone gets medicine at the University to develop vaccines.” professor in the university’s tested on arrival. He was of East Anglia, said, Jane Parry , Hamilton, Ontario department of medicine. asymptomatic but still “The evidence should Cite this as: BMJ 2020;370:m3340 the bmj | 5 September 2020 257

NEWS ANALYSIS How will l ifting the medical student cap work?

The limit on the number of medical students accepted into England’s universities was lifted last month after A level grades were awarded based on teachers’ predictions. Abi Rimmer examines the fallout

How will the change affect students? in “a higher likelihood of a greater than usual is now being coupled with cuts to hours The Department of Health has said that failure rate as students progress through their and, in some places, cuts to jobs. “We are where students have met their offer to study very demanding studies.” seeing clinical academics being asked if they at a medical school they should be able to Chris McManus, professor of psychology would defer their pay rises this year, as well take up that place this year or be guaranteed and medical education at University College as voluntary early retirement and voluntary a place at their chosen school in 2021-22. London, has conducted research that shows redundancy schemes,” he said. Additional teaching grant will be provided to that A level results, rather than predicted medical schools that take on extra students. grades, are the better predictor of how well a Why are universities struggling? student will perform at medical school. The pandemic has had a huge effect What was the previous limit? “There are always some students who are on finances, Strain says. “Universities Places were limited to around 7500 challenged by medical school,” McManus haven’t been applying for grants because of in England and 9500 in the UK. The England says. “When people let in students with lower the current environment, and the covid-19 figure, previously 6000, was increased by A level grades they tend to do less well. There studies that are being done are being done Jeremy Hunt while he was health secretary. is little doubt about that.” at a loss because the National Institute for Health Research only pays 80% of the What will it mean for medical schools? Will schools cope with more students? total cost of the study,” he says. “Some Medical schools usually make 20% David Strain, co-chair of the BMA’s universities have also handed back student more offers than they have places, because academic staff committee and a senior bursaries and accommodation fees, as well around 44% of students do not achieve clinical lecturer at the University of Exeter as losing fees from international students. their predicted grades. The Medical Schools Medical School, warns that many universities Charitable incomes have also fallen.” Council has estimated that because students are struggling. “We are going to have up to All this means universities will potentially have been awarded predicted grades this 20% more medical students in universities be in the red by hundreds of millions of year around 1600-2000 extra places will be that are desperately trying to get people back pounds at the start of the term, Strain warns. needed. Therefore univeristies are expected into some sort of lecture programme, while to take on more students this academic year, knowing that we don’t have the space for What does the government’s promised award deferred places for next year, or both. physical distancing,” he said. funding for the extra students cover? Medical schools are also suffering from Though an increase in teaching grant funding Will all these students cope? a declining clinician academic workforce, has been promised, it is unclear whether the The MSC has warned that awarding all with senior lecturer numbers falling by 27% additional students’ clinical placements will students their predicted grades could result since 2004. Strain warns that the decline be covered. The health department has said Medical student seeks amends for “racist” revue at Cardiff

A black medical student who harassment, her mental after moving to King’s. on year by other students and says she was targeted and felt health suff ered, and She has raised more professors was deeply painful. obliged to leave her course after she felt unable to stay than £7000 through “Eventually, I was part of a complaining about a racist show at Cardiff . She is now the crowdfunding group that called the institution at Cardiff University is taking in the fi nal year of her platform GoFundMe out on this. In raising this legal advice about how to hold medical degree at King’s and has found a law alarm, however, I was targeted the university accountable. College London. fi rm willing to take and became a victim of racial Natasha Chilambo, 25, was Chilambo told The BMJ she had on her case. She wrote on her harassment by students, doctors, one of eight third year students lost two years of study. “I was off fundraising page, “There was and other faculty members. who made a formal complaint university for a year,” she said. an annual production that “Eventually, my mental health about the 2016 medical school “I was not very well at all, and I used blackface and derogatory suff ered and I physically could revue, Anaphylaxis, which spent a year getting better.” She depictions of black people. not carry on studying. My story involved a student blacking up then had to repeat her third year Watching this get celebrated year is not unique: many people have and wearing an outsize dildo to portray a black lecturer. She says that after complaining CHILAMBO has raised more than £7000 so far through she was subjected to racial crowdfunding and has found a law firm willing to take on her case

258 5 September 2020 | the bmj “Black babies less likely to die when in care of black doctors”

Black newborn babies who are with white infants, is halved. cared for by black doctors are Strikingly, these eff ects appear to more likely to survive than those manifest more strongly in more cared for by white doctors, a US complicated cases, and when that work is being done to ensure placements study has found. hospitals deliver more black will be available but did not respond to Researchers analysed newborns.” questions about how they would be funded. 1.8 million hospital births in The researchers said it would Florida from 1992 to 2015 and be understandable for pregnant Will there be foundation training posts found that deaths were fewer women expecting to give birth for all future graduates? by 257 in 100 000 among black to a black baby to seek care from The BMA has warned that if foundation newborns in the care of black a black doctor; however, owing training posts do not align with future doctors, when compared with to the disproportionately white graduate numbers, the programme will be When people care by white doctors. The US workforce there were too few oversubscribed or, worse, graduates could let in students Centers for Disease Control black physicians to service the be left unemployed. Katie Petty-Saphon, with lower and Prevention reported last entire population. MSC chief executive, says the decision to A level grades year that, in 2017, the infant They also highlighted “the lift the cap came with the understanding it they tend to do mortality rate for black babies foundational concern of would require extra postgraduate training less well (10.97) was more than double capacity as well. “In our discussions with Chris McManus that for white babies (4.67). the Department of Health and Health Without controls, the Education England it’s clear that if you take researchers found that the on additional students this year then you raw mortality rate was not are looking at 10 to 12 years of education— statistically diff erent among undergraduate and postgraduate,” she says. white newborns under the care But Strain said the BMA was concerned it of white physicians (290 in would not get such guarantees. “When Hunt 100 000) or black physicians expanded places we asked if there would be (280 in 100 000). an expansion of foundation training posts. He However, under the care of said he couldn’t make assurances for another white physicians, the black SPL / FERMARIELLO MAURO government as there would be an election in newborn mortality rate was resolving the disparities in care that time,” Strain said. “There will, of course, estimated at 894 in 100 000 off ered by white physicians,” be an election before this cohort graduates.” births. Under the care of black adding, “Finally, it is important Abi Rimmer , The BMJ physicians this mortality rate was to note that physician Cite this as: BMJ 2020;370:m3358 estimated at 390 in 100 000. performance varies widely After applying a model that among both races, suggesting controlled for factors such that exclusively selecting on experienced similar diffi culties complained being ostracised. as insurance and common physician race is not an eff ective when they whistleblow. I The review, which reported comorbidities, the researchers solution to mortality concerns. want to fi nd a way to stop this in January 2017, made a found that black newborns had “These results underscore happening to others.” number of recommendations 430 more fatalities in 100 000 the need for research into drivers and highlighted “overarching births than white newborns of diff erences between high Investigation and review issues about the apparent and when under the care of white and low performing physicians, The university launched an disappointing lack of career doctors. Under the care of black and why black physicians investigation and suspended progression of BME staff .” doctors this diff erence dropped systemically outperform their the 32 students involved in the In a statement the university by 257 in 100 000 deaths (58%). colleagues when caring for revue. It also commissioned said, “We deeply regret and black newborns.” a n independent review, which apologise for the pain and Mortality penalty The authors noted some found a “major backlash,” upset this student led event The paper, published in the limitations of the study, including students who had caused our students. Given Proceedings of the National including that they were unable this matter could be subject Academy of Sciences of the to observe the “mechanism to future legal proceedings it United States of America, said, that is driving the observed would be inappropriate to off er “Findings suggest that when result, or the selection process of any further comment.” black newborns are cared for by the physician.” Clare Dyer , The BMJ black physicians, the mortality Elisabeth Mahase , The BMJ Cite this as: BMJ 2020;370:m3317 penalty they suff er, as compared Cite this as: BMJ 2020;370:m3315 the bmj | 5 September 2020 259 260 5 September 2020 | the bmj THE BIG PICTURE Flags of hope and gratitude

To pay tribute to people who have died from covid-19 and to honour the sacrifi ce of health workers in the NHS and across Europe, British artist Luke Jerram created the temporary installation In Memoriam. Shown here in Antwerp, the display has also been seen in London and will tour the UK and Europe in the coming months. In Memoriam, which is created from bed sheets, is intended to be an evocative symbol of local, national, and international solidarity and to off er a space for peace and contemplation. At the unveiling of his creation Jerram said, “With so much tragic loss over recent months I’m hoping the artwork may be of value to those experiencing trauma or bereavement.” Alison Shepherd, The BMJ Cite this as: BMJ 2020;370:m3383 JONATHAN RAMAEL/GDIF-WRIGHT JONATHAN the bmj | 5 September 2020 261 EDITORIAL Airborne transmission of coronavirus Guidelines and governments must acknowledge the evidence and take steps to protect the public

n July, 239 scientists signed plausible cause of superspreading an open letter “appealing events in a call centre in Korea, a choir to the medical community practice in Skagit County, US, and a and relevant national and restaurant in Guangzhou, China.1 - 14 I international bodies to The pandemic is at a critical juncture, recognise the potential for airborne and these strong signals should not spread of covid-19.”1 Although the be ignored by politicians and public World Health Organization conceded health leaders. that “airborne transmission cannot be Urgent research is needed to better ruled out,” the response was reserved understand airborne transmission and arguably mistaken in continuing and measure viral aerosol outputs to suggest that airborne and droplet during respiratory activity and transmission are discrete categories medical procedures. In the and that airborne transmission meantime, international guidance occurs only during medical “aerosol must acknowledge the weight generating procedures.”2 of evidence supporting airborne WHO defi nes droplets as ≥5-10μm Contact within are deposited along the respiratory transmission of covid-19 and include diameter and aerosols as <5 μm. households is tract; particles below 10 μm can recommendations to promote However, both can be generated thought to be penetrate as far as alveoli. eff ective preventive measures. during numerous respiratory responsible for The term “aerosol generating Inhalational risk may be reduced activities and their behaviours are roughly 70% of procedures” became popular after by social distancing, limiting not distinct. Aerosols are generated the 2003 SARS epidemic, when interaction indoors, avoiding air transmission when the surface tension of fl uid small retrospective studies found an recirculation, improved natural and lining the respiratory tract is association between transmission artifi cial ventilation, and innovative overcome by force.3 Heavy breathing, to healthcare workers and use of engineering solutions which collect coughing, talking, and singing procedures such as endotracheal and neutralise aerosols to provide all generate aerosols, causing an intubation and non-invasive clean air in personal and community exhalation plume of respiratory ventilation.9 This weak (grade D) spaces.14 The infection risk associated particles of varying sizes, containing evidence has been misused to infer with deep breathing, talking, and potentially infective viral material.4 - 8 a causal link between procedural singing indoors is underappreciated The high viral loads present in the aerosols and infection despite the and urgently needs attention. pharynx early in the course of covid- fact that aerosols were not measured Aerosol generating procedure 19 make these aerosols a plausible during these studies.9 Furthermore, is a misleading term.1 - 8 The cause of both pre-symptomatic and nurses were more commonly infected risk associated with individual asymptomatic transmission. than doctors performing procedures, procedures should instead be The arbitrary 5-10 μm threshold suggesting that proximity and time classifi ed by measuring aerosol commonly used to dichotomise exposed to patients with respiratory emissions, comparing them with airborne and droplet transmission Nick Wilson, distress are stronger determinants of those from other respiratory activities, has never been supported intensive care fellow, risk than the procedures themselves.3 and placing them in clinical context. theoretically or experimentally.4 Prince of Wales A prospective study sampling In the interim, healthcare workers Studies in both humans and airfl ow Hospital, Sydney aerosols during WHO defi ned aerosol require access to respirator masks models show that particles as large nickwilson247@ generating procedures in patients with for all high risk encounters, not just gmail.com as 50 μm can remain suspended infl uenza H1N1 found no signifi cant during selected clinical procedures. and travel considerable distances.4 8 Stephen Corbett, increase in airborne viral RNA.10 Controlling this pandemic is director , Centre for Furthermore, airborne range is diffi cult when the fundamental Population Health infl uenced by the force and volume and Western Clinical Strong signals science determining the response of exhalation as well as the local School, Western Since the 2003 SARS outbreak, is misunderstood. Accepting the 4 humidity, temperature, and airfl ow. Sydney Local research in aerobiology, physics, and importance of airborne transmission It is wrong to assume that droplets Health District and computational fl uid dynamics has may prove a crucial breakthrough land only on exposed mucosal University of Sydney advanced our understanding of aerosol and should not be delayed further. surfaces such as the eyes and Euan Tovey, generation and the carriage and fate Cite this as: BMJ 2020;370:m3206 mouth.4 Particles up to 50 μm can be associate professor , of respiratory particles.1 - 14 Airborne Find the full version with references at captured by inspiratory airfl ows and University of Sydney transmission of covid-19 is now the http://dx.doi.org/10.1136/bmj.m3206

262 5 September 2020 | the bmj EDITORIAL Covid-19: preventing household transmission We urgently need new measures to protect contacts within our homes

he UK is one of the countries most severely aff ected by covid-19. Recent T outbreaks in English towns such as Oldham, probably involving transmission within large multigenerational households, show the importance of getting the right public health measures in place now to prevent more widespread surges in infections.1 Current test and trace policies Contact within have underlying medical conditions, and Lithuania.17 In China, fi eld have mainly focused on preventing households is or share a bed or vehicle with the index hospitals were created to manage and spread in care homes, hospitals, and thought to be case are the most susceptible.9 - 12 strictly isolate patients with mild-to- 2 18 in the community. However, contact responsible for Governments should consider new moderate covid-19. Nightingale within households is thought to be roughly 70% public health measures to prevent hospitals in the UK could be similarly responsible for roughly 70% of SARS- of SARS-CoV-2 household transmission as we prepare repurposed to support isolation CoV-2 transmission when widespread for a potential second wave. Household of infected people with mild-to- community control measures are in quarantine is likely to remain an moderate disease. However, such a place.3 In Wuhan, the reproduction important pandemic control measure, system depends on access to rapid number (R) dropped from 3.54 to and government support for people testing for anyone with symptoms or 1.18 after lockdown and cordon quarantined at home is conspicuously possible exposure so that infection sanitaire. But the epidemic was only absent in the UK: this position has been can be confi rmed and isolation brought under complete control challenged by independent experts.1 5 started before transmission occurs. It when Fangcang (fi eld) hospitals were would also require public trust that introduced to isolate cases outside Effective isolation isolation in these facilities would be the home, with R dropping to 0.51 Eff ective isolation of index cases from voluntary, safe, and supportive. after two weeks.4 household members could reduce Important questions about Current UK guidance advises secondary infections.12 Wearing masks household transmission remain. household contacts to isolate within within quarantined households may Research should be done to identify the same home as the index case for help, particularly if used by the index the determinants of household 14 days.5 They make up the majority case as soon as infection is suspected.16 transmission and the optimal Shamil Haroon, of contacts for infected individuals The World Health Organization strategies for isolating cases and clinical lecturer in and are likely to remain exposed primary care recommends that infected people protecting household contacts. These to the infected household member s.haroon@ and unavoidable close contacts, strategies will be particularly important during this period of isolation.6 bham.ac.uk particularly those in vulnerable for those at higher risk of adverse Despite guidance advising household Joht Singh Chandan, groups, should wear medical masks, outcomes, including ethnic minority members to socially distance, contacts academic clinical but does not communities, people in low income are likely to interact repeatedly— fellow in public currently recommend this. Other households, and those living in urban during mealtimes, for example—and to health, University of measures that should be considered areas with overcrowded housing. share facilities such as bathrooms. Birmingham (and evaluated) include clear advice Until an eff ective vaccine is widely We know that transmission is more John Middleton, on enhanced personal hygiene; available, strategies to prevent likely to occur indoors than outdoors. 7 president , cleaning and disinfecting shared household transmission and to The cumulative risk to household Association of toilets and other common spaces, support those in quarantine will be Schools of Public contacts from an infected person is door handles, and touch points; and vital and should be a core part of any Health in the likely to be substantial during peak staggering mealtimes. government’s strategy. It is high time European Region viral shedding. In one study in New (ASPHER) People who are unable to self- that the UK government amend its York State, 38% of household contacts Kar Keung Cheng, isolate safely at home could be mantra of “test and trace” to “test, tested positive for SARS-Cov-2, and professor of public accommodated in special isolation trace, isolate, and support.” similar secondary infection rates health and primary facilities such as hotels and hostels, Cite this as: BMJ 2020;370:m3181 have been reported in China. 8 9 care , University of an approach adopted by some other Find the full version with references at Household members who are older, Birmingham countries, including Italy, Finland, http://dx.doi.org/10.1136/bmj.m3181 the bmj | 5 September 2020 263 PROFILE Dido Harding: the former business leader now in charge of England’s covid response What are the personal qualities, leadership style, and values of the woman appointed to the nation’s most high stakes health role, asks Gareth Iacobucci

DIDO HARDING’S CV ppointed interim someone who has “forged a career chair of the National out of crises.” 1985-88 University of Oxford, where she studied politics, Institute for Health Harding’s appointment to lead philosophy, and economics Protection at its the agency has also prompted 1990-92 MBA at Harvard Business School inception last accusations of cronyism and 1992-2010 A Roles at McKinsey, Thomas Cook, Woolworths, month, the Conservative peer Dido nepotism: she was made a life peer in , and Sainsbury’s Harding has been handed one of 2014 by , with whom 2010-17 Chief executive of TalkTalk Telecom (below) the most high profi le—and highly she studied at Oxford, and is married 2014 Appointed to as a Conservative peer scrutinised—jobs in England. to the Conservative MP , (Baroness Harding of ) The stakes are high: the new agency who is a board member of the think 2014 to present Non-executive director and chair of has been tasked with overseeing the tank 1828, which has called for remuneration committee, nation’s covid-19 response, after the the NHS to be replaced by a social 2017 to present Chair of NHS Improvement government’s controversial decision insurance system. 2018 to present Board member of the , which to disband Public Health England , England’s secretary runs many of the biggest events in British horseracing, and merge its health protection of state for health and social services, including functions with the Joint Biosecurity insists that Harding is the right 2020 to present Chair of NHS Test and Trace, and interim Centre and the NHS Test and Trace person to lead the institute, citing chair of the new National Institute for Health Protection service, which Harding has led since her “excellent experience externally, it launched in May. where she has run very large Questions have been raised about organisations.” Harding’s lack of expertise in public A Department of Health and Social health and the patchy performance Care spokesperson said, “Baroness of Test and Trace on her watch. Harding has been appointed due to While she has chaired the regulator her wealth of relevant experience NHS Improvement since 2017, she in healthcare and her leadership of made her name in business, rising large organisations and programmes. through the ranks of the likes of the We have no doubt that, under management consultancy McKinsey Baroness Harding’s leadership, the and the supermarket chains Tesco NIHP will be established as a thriving and Sainsbury’s. mission-driven organisation.” A turbulent spell in charge of the broadband company TalkTalk, “Engaging and interested” during which it received a record So what is her leadership style, and £400 000 fi ne from the UK how will her values and approach information commissioner for a huge shape the new institute? data security breach, prompted the Reports describe her as “super- Times JOHN NGUYEN/SHUTTERSTOCK to describe her last month as driven,” big on detail, and—perhaps

264 5 September 2020 | the bmj unsurprisingly, given her retail engaging, very interested, and had a is),” he wrote in a blog post after background—someone who places good modern leadership style quite her appointment. “It’s the way the a lot of value on getting customer unlike the typical NHS England style appointment was made that makes experience right. of command and control.” everything so murky and this is a Last year she led a review of NHS Andy Knox, a GP in Lancashire and great shame.” workforce challenges and mapped the director of population health for out her ambition for the NHS to be the Morecambe Bay Health and Care The right expertise? “a modern, caring, and exciting System, has met Harding through his Perhaps, given her well publicised workplace that should be the best involvement with the NHS Assembly. background, only Harding’s actions place to work in England.” She has He echoes these thoughts on her and performance in her new role called for national regulators to stop leadership, describing her as having a will alter perceptions about her “encouraging the wrong kind of “genuinely humble desire to listen and She is a true appointment and show whether she behaviour” by prioritising fi nancial treat people with kindness.” ally of race has the necessary expertise. performance ahead of staff wellbeing. equality and In 2018, shortly after she joined A certain steeliness is also evident. Conflicts of interest inclusion NHS Improvement, Richard Smith, In 2018 she told The BMJ that good But while her leadership style may Mala Rao former editor of The BMJ, reported on management isn’t “soft and fl uff y” have won her admirers, her links a speech she gave on organisational but is “about giving or having honest to business and the Conservative management to the Cambridge Health adult conversations.” That same year Party have led some to label her Network, in which she emphasised she told the HSJ that she wanted the appointment as cronyism. “However the importance of collaboration and NHS to stop “recycling” senior NHS good a person she is, I think she is locally driven change. managers who crossed “a moral line” tainted because of all these confl icts This, and testimonies from in their conduct. of interest,” says the doctor who people who have dealt with her Since joining the NHS Harding has spent time with Harding. “She is professionally, indicates that she evinced a commitment to inclusion part of a system that is seen to be will not run the new institute in an and tackling race inequality, in her very nepotistic.” autocratic fashion. public pronouncements and her Harding has not hidden her More broadly, Rao says that having work with the NHS Workforce Race political affi liation and loyalty to the Harding has a business background should not Equality Standard (WRES) Strategic Conservative Party. She has never a genuinely preclude someone from running Advisory Group. voted against the Tory whip. And humble desire a public health agency, provided Mala Rao, professor of public in 2017, when she became chair of to listen they have the requisite leadership health at Imperial College London NHS Improvement, she refused a Andy Knox and people skills. “I think it matters and a medical adviser to WRES, says, request by the House of Commons whether chairs listen, respect the “I have been fortunate to work with Health Committee to sit as a cross evidence put to them by their experts, Baroness Harding in her capacity as party peer to demonstrate personal ask questions, and have a deep a member of NHS England’s WRES independence in the role. interest in improving the health of the Advisory Group. She is a true ally At the time she argued that population,” she says. of race equality and inclusion, and “pretending to be unaligned In terms of England’s response to I have felt especially encouraged politically . . . would not be being the covid-19, Harding has been explicit by her support for the WRES and, honest and straightforward person I that there should be more emphasis in particular, the work I am leading am,” but added, “I do not see this as on local testing and tracing, and that a focused on the medical workforce.” a political appointment and I will do digital app should be a supplementary Rao says she had also heard my utmost to demonstrate that.” tool, suggesting she is willing to break Harding speak at events held by After Harding’s appointment to the from previous orthodoxy. “Give her medical diaspora organisations, institute the Liberal Democrat MP Her appointment her dues: she has recognised what where “her empathy with these Layla Moran, who chairs the All-Party has undermined the problem is and has come the organisations and knowledge of Parliamentary Group on Coronavirus, public trust in closest [of any national leader] to racism as a social determinant of was among those to be critical. “The the new agency admitting that they got it wrong with health have been evident.” health secretary has undermined Layla Moran all the apps, etc,” says the doctor who Rao adds, “My conclusion is that public trust in this new agency before met Harding. she will take these attitudes and it’s even been launched,” she said. Observers from the public health her knowledge base to the new Knox says that Harding’s community and beyond will institute, and that bodes well for the appointment was clearly “not hope to see more evidence of this organisation, especially against a aligned” with the Nolan principles of straightforward and open minded background of the disproportionate public life and that the government approach as the country moves to impacts of covid-19 on BAME people.” had “serious questions to answer.” the crucial next phase of its covid-19 An NHS doctor who met Harding at “It’s not that Dido Harding (who response. his place of work gives this account, called for more integrity in NHS Gareth Iacobucci, chief reporter, The BMJ speaking anonymously to The BMJ: leadership) is necessarily the wrong [email protected] “Dido came to visit us. She was very person (although many feel that she Cite this as: BMJ 2020;370:m3332 the bmj | 5 September 2020 265 BRIEFING Covid-19: the problems with case counting Novel c oronavirus cases in England have been rising steadily since the beginning of July. However, this trend may not tell us what we really need to know about the pandemic and the most serious cases—or what to do about them, reports Elisabeth Mahase

Official reported estimates n the week 10-16 August, At the moment it seems that a 3.0 covid-19 case detections in polymerase chain reaction (PCR) 2.5 England rose to 6418, from positive result is the only criterion 5763 the week before, Public required for a case to be recognised. 2.0 I Health England’s surveillance “In any other disease we would 1.5 report shows. This fi ts in with the have a clearly defi ned specifi cation

Incidence rate per 1.0 wider trend of a steady increase in that would usually involve signs, cases since the beginning of July. symptoms, and a test result,” says 10 000 people per day 0.5 So, is this the much feared second Carl Heneghan, director of the 0 wave? Experts are increasingly Centre for Evidence Based Medicine concerned that these headline at the University of Oxford and Modelled estimates fi gures don’t provide a clear picture the editor of BMJ Evidence-Based 3.0 of what’s really happening in the Medicine. “We are moving into a 2.5 pandemic—or how we should biotech world where the norms of 2.0 respond, such as with local clinical reasoning are going out of lockdowns. the window. A PCR test does not 1.5 After 17 August, estimate has a greater level of uncertainty because equal covid-19; it should not, but in of lab results still being processed Incidence rate per 1.0 What is a “case”? some defi nitions it does.”

10 000 people per day 0.5 One issue in trying to interpret Angela Raffl e, honorary senior 0 numbers of detected cases is that lecturer in social and community 11 1 22 13 20 there is no set defi nition of a case. medicine at Bristol Medical School, May Jun Jun Jul Aug is also concerned about this. She says, “In the early phase back in Pillar 1 cases Pillar 1 (positivity %) March, deaths were just reported Pillar 2 cases Pillar 2 (positivity %) 30 48 numbers—you couldn’t tell quite what was being counted—then after 25 40 a while the small print appeared defi ning what is counted as a covid- 20 32

Positivity (%) 19 death. 15 24 “I'm still waiting to see the small No of cases (000s) print to clarify what we are counting 10 16 as cases.” Both Heneghan and Raffl e say 5 8 that it’s hard to compare the fi gures 0 0 on cases over time because the 567891011 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33* way we defi ne a case seems to have Sample week changed, moving from people with *For the most recent week more samples are expected, so the decrease seen in this graph should be symptoms who have then tested interpreted with caution. The data are shown by the week the specimen was taken from the person being tested. This gives the most accurate analysis of this time progression, but it does mean that the positive to a PCR positive result latest figures may be incomplete alone, regardless of symptoms.

266 5 September 2020 | the bmj of the test, it can pick up a single Raffl e says, “As the country strand of viral RNA—but this doesn’t opens up, more younger people test necessarily equate to someone being positive than older people as more infected or infectious. younger people are out and about— Heneghan says, “If you go into in large groups, potentially. Younger a community population you are people are also more likely to go on going to pick up more SARS-CoV-2 foreign holidays at the moment, as RNA for which you don’t understand well. the importance of what that means, I’m waiting for “This group is less likely to need particularly if you don’t interpret it in clarification on hospital admission.” the context of symptoms or viral load. what we are Many of these people might have had Local lockdowns counting an active infection some weeks ago Angela Raffle While the testing data are so opaque, and are still carrying the RNA in their using them to direct local lockdowns nasal swabs: it might not actually be is unhelpful, argues Heneghan. “The live virus that you are picking up.” testing is there to drive the test and trace strategy,” he says. “But what Hospital admissions seems to be happening is that, as PETER MACDIARMID/SHUTTERSTOCK The most important measure should soon as we see an outbreak, there be the disease’s impact, Heneghan tends to be panic and over-reacting. Detecting asymptomatic cases adds. It’s important to know, he says, This is a huge problem because We could be seeing a rise in detected whether the rise in detected cases is politicians are operating in a non- asymptomatic cases. While “the due to more people presenting to the It might not be evidence-based way when it comes to number of detected cases are rising, healthcare system with symptoms, as live virus you non-drug interventions.” that is not the same as cases rising,” these are the cases that aff ect hospital More attention should be paid are picking up says Heneghan. admissions. Carl Heneghan to hospital admissions and cases The latest infection survey by the In fact, while case numbers have with symptoms, he believes. “PCR Offi ce for National Statistics (21 been rising, little change has been testing should drive the test and trace August) showed that the incidence seen in hospital admissions. Both the strategy. That’s separate to a strategy rate for England had “levelled off ,” government’s covid-19 dashboard on restrictive measures and what is as had the percentage of people and the weekly reports show happening with the disease impact,” testing positive for covid-19. that admissions and deaths have he says. “When there is an outbreak Heneghan explains, “It is in the remained stable and may have even the question they should be asking background, circulating at low slightly declined. is, how does this translate into the levels; most of the people who have it Pollock says, “It’s very diffi cult to impact of the disease?” are asymptomatic.” interpret what is going on because On top of this, Pollock says that the Allyson Pollock, co-director of hospital admissions don’t seem to It’s difficult to government needs to get the statutory the Newcastle University Centre be rising, although we may still see a interpret what notifi cation system working so that for Excellence in Regulatory spike. Is it that we’re picking up cases is going on suspected cases can be reported. Science and an Independent SAGE in a diff erent population—those who Allyson Pollock “GPs were cut out of covid care from committee member, says that are healthier? Is the virus attenuating the start, and they are still cut out symptomatic and asymptomatic in some way? Or is there more of it,” she explains. “We should be cases need to be separated out, to background immunity?” ensuring that suspected cases in the enable the government and local community are reported, and that public health teams to understand Detecting cases in younger people should work as an early warning what’s happening. Alongside the increased detection system and trigger contact tracing. Heneghan suggests that, although of asymptomatic cases, another We have really failed in that, and as a this isn’t currently done, pillar 1 possible explanation for hospital result we don’t have good community data (which include tests done in admissions not correlating with the data, and the data we do have is hospitals) can give some indication. increase in cases could be a rise in the messed up because we are adding “Generally, you look to pillar 1 data, number of detected cases in younger into the mix cases identifi ed through and that has stayed pretty fl at,” he people: a healthier population, as mass testing of asymptomatic people. says. “What we are [now] picking Pollock hypothesises. “It’s a mess, it’s chaotic. The up is pillar 2, which is lots of case Age is a factor in the risk of government should separate out fi nding in the community.” developing serious illness, and being the reporting of test data now. They over 70 is enough to put someone should also bring GPs back into the PCR sensitivity into the NHS’s moderate risk system properly.” Another problem with relying on PCR category. Recent fi gures show that the Elisabeth Mahase, The BMJ testing alone to defi ne a covid-19 highest rates of new detected cases [email protected] case is that, owing to the sensitivity were in the 15-44 year age group. Cite this as: BMJ 2020;370:m3374 the bmj | 5 September 2020 267 TESTING A covid-19 laboratory for Jersey— in a shipping container Small mobile facilities could prove a useful tool in the pandemic response—and are being trialled in the UK, reports Chris Baraniuk

he island of Jersey has a new tool laboratory, in contradistinction to building a It was the most in its covid-19 testing toolbox: a laboratory yourself.” efficient, rapid laboratory built inside a shipping The design for OpenCell’s compact, way of setting up container that can process 2000 transportable laboratory was developed a new system T reverse transcription PCR tests in partnership with King’s College London Ivan Muscat, every 24 hours. It was delivered to a car park and Opentrons, an open source laboratory Jersey government behind Jersey’s only airport in July. equipment fi rm. The 40 ft shipping To date, covid-19 diagnostic tests on the containers can be transported by road, rail, had to rely in part on rapid molecular tests, island have been processed using a mix of air, or sea and, once deployed, require six which are easy to use but also expensive. “It local facilities, and laboratories in the UK. members of staff working in shifts. They are really is pretty low volume; some of these you Although PCR capacity is limited to 2000 equipped with robotic machines that can can only do one at a time,” says Wilson. a day, the acquisition of more machines handle samples and fl uids—but, at heart, Testing capacity within the NHS and at will expand this by the end of the month. are traditional PCR laboratories, albeit with the government’s lighthouse laboratories Two fl ights a day deliver swab samples to a a streamlined process. They are designed to has grown signifi cantly since the early laboratory in Coventry, with results usually meet at least biosafety level two. days of the pandemic, Wilson notes, so the available within 30 hours. Meany says his fi rm is now manufacturing usefulness of small, on site testing facilities “All we’re responsible for is increasing the laboratories for other clients, with one would be limited. In the case of a signifi cant that speed,” says Tom Meany, co-founder already on its way to Pakistan and another to local outbreak in an urban area, for example, of OpenCell, the London based biomedical an undisclosed UK location. While eff orts to Wilson thinks it would be simpler to courier a start-up that designed and built the lab. ramp up covid-19 testing capacity in the UK higher volume of swabs to the existing, larger and elsewhere around the world have largely laboratories rather than rely on a rapidly Testing travellers focused on established hospital laboratories deployed mobile lab. When visitors arrive in Jersey by air or sea they and centralised facilities equipped to process In Jersey, the container may fi nd its can choose to be swabbed for covid-19 or to many thousands of tests per day, small, purpose. For now, Meany and his team are self-isolate for two weeks, unless they have mobile laboratories have also been used. carrying out checks to ensure that tests can travelled from areas the local government has be processed accurately. To date, OpenCell deemed present greater risk of exposure to the Boosting capacity has not published detailed validation data virus. Many of these swabs will be processed Take, for instance, the fi eld laboratory fi rst showing that their model is as reliable as in the shipping container lab. used in Africa during the Ebola outbreaks other laboratory formats. But Jersey, Meany Ivan Muscat, a consultant microbiologist in 2014 and 2015, which was repurposed and Muscat hope, will be a key proving and deputy medical offi cer of health for the for covid-19 testing and shipped to Italy in ground. Jersey government, says the facility could text June. The following month, a mobile lab was If successful, it could pave the way for negative test results to travellers in as little as installed in the grounds of Bohol Medical Care similar projects to bring testing facilities four hours. It may take longer to communicate Institute in the Philippines. In both cases, the much closer to the point of care in some positive results, as these will be reported to aim was to boost overall testing capacity and cases—although centralised facilities still individuals directly by contact tracers. provide results quickly to people on site. look set to carry out the vast majority of “It seemed like the most effi cient and In these contexts, mobile laboratories can covid-19 diagnostics around the world. rapid way of setting up a completely new prove useful, says Allan Wilson, president Chris Baraniuk, journalist , Belfast, UK system,” says Muscat of the container lab. of the Institute of Biomedical Science in the [email protected] “It was, if you like, an off -the-shelf complete UK. Some Scottish islands, for example, have Cite this as: BMJ 2020;370:m3336

268 5 September 2020 | the bmj