2020

Evaluation of the Lateral Flow Device Testing Pilot for COVID-19 in Merthyr Tydfil and the lower Cynon Valley

MERTHYR TYDFIL COUNTY BOROUGH & LOWER CYNON VALLEY

(RHONDDA CYNON TAF

COUNTY BOROUGH)

SECTION CONTENT PAGE 1 Foreword 3

2 Executive summary 5

3 Introduction 9 3.1 Purpose 3.2 Pilot aims and objectives 3.3 Demography of pilot areas 3.3.1 Deprivation in pilot areas 3.3.2 Black and ethnic minority populations

3.4 Epidemiology of COVID-19 in the pilot areas 3.4.1 Positivity rates and lockdowns

3.5 Testing strategy 3.6 Hypothesis to test through assessment of mass testing

4 Governance, planning and implementation 17 4.1 Governance 4.2 Planning 4.3 Implementation

5 Logistics 26 5.1 Community based testing 5.1.1 Home testing arrangements

5.2 Contact tracing 5.3 Protect 5.3.1 Cwm Taf Morgannwg Self Isolation Helpline

6 Schools based testing – Merthyr Tydfil and lower Cynon Valley 37 6.1 Communication and engagement 6.2 Secondary school mass testing – Merthyr Tydfil 6.3 Secondary school mass testing – lower Cynon Valley 6.4 Resources 6.4.1 Workforce resources 6.4.2 Logistical resources 6.4.3 Financial resources

6.5 Testing and analysis of uptake outcomes 6.5.1 Uptake 6.5.2 Positivity rate by age group

6.6 Comparisons, learning from other areas 6.7 Systems and process working

7 Resources 53 7.1 Workforce resources 7.2 Logistical resources 7.2.1 Physical infrastructure 7.2.2 Equipment and support services

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7.3 Financial resources

8 Analysis of testing uptake and outcomes 65 8.1 Uptake of testing 8.1.2 Age and gender 8.1.3 Deprivation 8.1.4 Occupation

8.2 Positivity 8.3 Lateral Flow Device tests 8.4 Estimated cases, hospitalisations and deaths prevented 8.5 Economic evaluation 8.6 Waste water testing

9 Communication and engagement 97 9.1 Merthyr Tydfil 9.2 Lower Cynon Valley

10 Operational research for risk factors in transmission including 104 behavioural insight 10.1 Case control study

11 Comparisons – learning from other areas 107 11.1 Liverpool 11.2 Scotland

12 Conclusions 113

13 Recommendations 117

14 Contributors 123

15 Appendices 124

Date of publication

22nd March 2021 (Version 1)

25th March 2021 (Version 2)

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1. FOREWORD

Dear Colleague

It gives me great pleasure, as the Senior Responsible Officer for the Cwm Taf Morgannwg Test Trace Protect Service and Director of Public Health for Cwm Taf Morgannwg University Health Board, to present this evaluation report on the Whole Area Testing pilot we ran in November and December 2020, in the County Borough of Merthyr Tydfil and the lower Cynon Valley area of Rhondda Cynon Taf County Borough.

The last 12 months have been a ‘roller-coaster’ for us all. As the COVID-19 pandemic hit, we have all had to make sacrifices in our lives, both as individuals, communities and as a nation, standing together.

As public services, together with the support of government, Military, the Third Sector and private sector partners, we have had to rapidly establish Test Trace Protect services to help prevent the spread of the virus and to protect our most vulnerable people living in our communities. This has been a huge testament to partnership working across Wales and certainly within our region. The collective effort which has gone into the development and running of these services has been remarkable, given all the challenges we have faced so far, and I must express my sincere thanks to all partners and communities involved.

The implementation of a testing service to detect the COVID-19 virus has been part of that enormous effort. Initially we had been testing those individuals who had COVID-19 symptoms and encouraging them to come forward for a PCR (Polymerase Chain Reaction) test. More recently, technologies have developed and we are now able to offer individuals without symptoms an LFD (Lateral Flow Device) test. These test can provide results in as little as thirty minutes or less, whereas a PCR test usually takes between 24-48 hours, as it is done in a laboratory.

It was this pioneering use of LFD tests that we wanted to pilot in some of our communities, particularly those at the time who were experiencing some very high and stubborn COVID-19 incidence and positivity rates. One of our main reasons for doing this was to support these local communities in their efforts to stop and reduce the community spread of COVID-19 to as low as reasonably possible, in order to save lives, save livelihoods and businesses.

I must pay testament to our partners and communities in the implementation of this pilot. This was very much locally led and driven, with excellent leadership from both Local Authorities, great involvement from the Third Sector and Military, and fantastic team-working on the ground. Particular mention should be made in both areas to the dedication and hard work of all teams pulling together to deliver a challenging pilot in terms of logistics and communication in such a tight timescale. For many staff this was in addition to their ‘day jobs’ and involved working seven days a week for the planning and implementation periods.

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I know there are concerns expressed about LFD testing and how accurate a test it is, which the report usefully provides further details on; however there are also some key benefits which we wanted to explore further, as part of working with and supporting our communities.

In its conclusion therefore, I am pleased to see that the evaluation report demonstrates that as well as having good community support and attendance rates for LFD testing, most importantly this had an immediate, positive impact on the level of COVID-19 circulating in those communities and would likely have contributed to the subsequent decline in COVID-19 case rates which occurred, following the testing pilot and the introduction of the national lockdown, implemented on 20th December 2020. The report usefully demonstrates that an estimated 353 cases (both asymptomatic and symptomatic), 24 hospitalisations, 5 ICU admissions and 14 deaths, that would have otherwise occurred without the implementation of the pilot, were prevented.

These are exciting conclusions and whilst LFD testing is not perfect, I hope this report will help inform the future potential use of LFD testing, as part of a wider testing strategy. It has the potential to be a key part of our whole Test Trace Protect system as we look more confidently towards recovery in Wales and it provides useful learning from experience for other areas who may be considering implementing a similar approach.

Professor Kelechi Nnoaham MD, DPhil, FFPH

Executive Director of Public Health

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2. EXECUTIVE SUMMARY

Background

Merthyr Tydfil and Rhondda Cynon Taf have been the Welsh Local Authorities with the highest incidence rates of COVID-19 in the UK along with associated illness and deaths. The Welsh Index of Multiple Deprivation shows that Merthyr Tydfil and the lower Cynon Valley have some of the most deprived areas in Wales. In addition, smoking rates are high in both areas in comparison to the health board and the Welsh average, and there are high levels of overweight and obesity and higher prevalence of long term conditions. These factors are all inevitably associated with the poor outcomes we have seen.

Pilot aims and objectives

In the context of persistently high rates and with the agreement and support of Welsh Government, the Whole Area Testing Pilot (WATP) was set up and led by the Cwm Taf Morgannwg (CTM) Test Trace Protect (TTP) Service, which reports into the group of Local Authority and Health Board Leaders/Chair and Chief Executives in CTM. The Senior Responsible Officer (SRO) for the pilot was the CTM Director of Public Health/Chair of the CTM TTP Service. The Military worked closely with the TTP service to deliver the pilot to explore the potential for mass testing.

The aims of the pilot were agreed as follows: 1. To test whether or not large-scale testing using LFD can yield a significant and sustained reduction in community transmission. 2. To make testing accessible to an agreed area(s) entire population and incentivise uptake. 3. To identify index cases and prevent further transmission through contact-tracing and other measures. 4. To protect those at highest risk. 5. To empower the local community to arrest and reduce the community spread to as low as reasonably possible in order to save lives and save livelihoods and businesses. 6. To identify those who are needlessly self-isolating and empower them to return to usual activities. 7. To assess the impact of testing on behaviour of participant.

The objectives of the pilot were to: 1. Develop a blueprint for whole town, city, borough or regional testing. 2. Better understand prevalence via asymptomatic surveillance. 3. Develop an intelligence picture and use asymptomatic testing to limit an agreed area’s acceleration through enhanced restrictions escalation. 4. Deploy new technologies in an agile and scalable way.

Planning and Implementation

A working group was established to lead the pilot, chaired by the SRO and members included representation from the two Local Authorities involved, the University Health Board (UHB), Welsh Government, Welsh Ambulance Service Trust, Police, Local Resilience Forum, Military and the Third

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Sector. The group met daily, including weekends, during the planning, implementation and early delivery period of the pilot due to the intensity of the work required and tight timescale.

A number of critical elements assisted the set-up. These included the development of the Concept of Operations, a draft template clinical standard operating procedure (SOP), the development of a Whole Area Testing pilot over-arching Standard Operating Procedure, the Military Planning Aide memoir and Maintenance of a ‘Lessons Learned Log’. Comprehensive communications and engagement plans were also developed.

Implementation of the pilot was very much locally led and driven. In the Merthyr Tydfil area, implementation was led by the Local Authority in partnership with the Military. In the lower Cynon Valley, where the pilot commenced two weeks later, this was led at local level by the Local Authority, having observed and learned from colleagues in neighbouring Merthyr Tydfil. There was excellent leadership from both Local Authorities involved from the Leaders and Chief Executives to senior officers and officers on the ground. In both areas, the pilot benefitted greatly from the dedication and hard work of all teams pulling together to deliver a logistically challenging pilot in such a tight timescale.

A hub and spoke method of delivery was developed with central testing stations in larger population areas, supported by mobile stations serving smaller communities.

A pilot was also undertaken in secondary schools, a special school and a pupil referral unit in the areas to increase access and uptake among 11 – 16 year old children and young people. Those in further education were proactively linked into community testing facilities. Home testing was offered to all those who were on shielding lists, with PCR test kits sent to homes.

Merthyr Tydfil has a population of just over 60,000 people and the pilot was agreed to run for a three week period, commencing 21st November 2020. In the lower Cynon Valley area, with a population of about 26,000 people, the pilot was agreed for a two week period, commencing 5th December 2020. The pilots commenced shortly after the Welsh Governments Firebreak which ended on 8th November 2020, which had resulted in a reduction of incidence and positivity.

A self-isolation helpline was established to provide information and advice along with support to follow self-isolation guidance for those testing positive. The Protect work stream linked together the Local Authorities and Third Sector to provide the support available.

Analysis of uptake and outcomes

Community response to opportunity to participate in LFD testing was very high with uptake at 49% of the target population in Merthyr Tydfil and 56% in the lower Cynon Valley. This compares very favourably with the uptake in Liverpool and Scotland pilots of between 25-33%, which were undertaken at similar times. There was lower uptake in males, younger people (11-29 years) and those living in the most deprived quintiles of the population. The vast majority of those attending were asymptomatic, at 99.6%.

The home tests available to those shielding was the PCR test, which was different to the LFD test available in community settings. The uptake of the home tests was 36% in Merthyr Tydfil and higher at 45% in the lower Cynon Valley, the telephone calls were made to those eligible to explain and encourage uptake.. This is much higher that the Liverpool pilot where completion was 8.3%.

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The positivity rate for those having the LFD test was 2.3% in Merthyr Tydfil and 2.6% in the lower Cynon Valley with higher positivity rates in males (2.6% Merthyr Tydfil, 2.9% lower Cynon Valley), younger people (20-29 years 3.2% Merthyr Tydfil, 4.2% lower Cynon Valley), those living in the most deprived areas (3.1% in Merthyr Tydfil, 2.7% lower Cynon Valley) and in occupational groups where close contact was more likely, including transport (5.2% Merthyr Tydfil) manufacturing and construction (5.6% lower Cynon Valley), hospitality, health and social care, retail, and arts and entertainment. In addition there was a high rate of positivity in those that did not disclose an occupation (3.2% in Merthyr Tydfil, 5.5% in lower Cynon Valley).

The lower uptake in the groups that had higher positivity rates would indicate an “Inverse Testing Law”. This lower uptake in these groups could reflect the bigger impact of potential self-isolation on their financial position, underlining the inequalities in risk and outcomes experienced by these groups.

As a result of the whole area testing pilot in Merthyr Tydfil alone, it is estimated that 353 cases (both asymptomatic and symptomatic), 24 hospitalisations, 5 ICU admissions and 14 deaths, that would have otherwise occurred, were prevented. When taking into account multiple generations of infection that would have occurred in the community, over a tenth of cases that would have occurred over a 6 week period were prevented. This forecast translates into a predicted of 6-12% reduction in burden on the healthcare system. These forecasts are based on a probable, but conservative scenario.

Economic analysis

The cost of the pilot and tests varied with population size in each area. This was due to the fact that although planning, infrastructure and operational costs in both areas were similar, the target populations and tests undertaken were different. The average cost of community testing per test was £20, school testing was £21 and home testing £38.

To compare costs and outcomes at a Local Authority level, the cost of the testing pilot in Merthyr Tydfil, £515,618 was used to undertake a cost effectiveness analysis. The quality-adjusted life years (QALYs), a measure of disease burden, including the quality and quantity of life lived was calculated. The pilot was found to be highly likely to be cost effective, with an incremental cost effectiveness ratio of £2,292 per QALY gained. Net monetary benefit for the intervention, which is cost savings plus the value of QALYs gained was £5.8million.

Case-control study

A case control study was undertaken by Public Health Wales at the same time as the pilot, and provided useful intelligence on factors affecting transmission in this population. The transmission within the household was the most important source of SARS-CoV-2 infection. Working in the hospitality sector, and visiting the pub were significant risks but at the time of this study were relatively infrequent exposures. Smoking or vaping had a small but significant effect. Working in education, living with someone working in education, having caring responsibilities and visiting a supermarket, restaurant, gym or leisure centre did not appear to increase risk of infection.

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Waste water testing

Partners had been keen to support the use of waste water sampling to inform community testing undertaken during the pilot. The results of the waste water sampling were not available at the time of the pilot to inform the location of sampling. However, the results did show a potential to provide information about the relative burden of COVID-19 infection and may benefit from further research. Compared with that of larger towns and cities (>100,000), data were found to be highly variable in wastewater networks serving relatively small populations (<10,000), producing spikes in the daily data and making results more difficult to interpret. The results confirmed that waste water testing has potential to provide information about the prevalence of COVID-19 to inform the selection of Asymptomatic Test Sites. Lead times of several days are necessary to identify and assess suitable sampling sites, regular sampling, processing and analysis. In addition, reporting procedures need to be more streamlined and nearer real time for wastewater data to help inform testing strategies.

Communication and engagement

The locally led communication and engagement strategy achieved the required outcomes of getting a high level of the population tested. Throughout the testing programme, a close watch was kept via social media channels on what the public were saying and their experience of the testing centres. As a result of this, there was the continual ability to adapt the communication strategy to reflect public sentiments and respond to queries and concerns.

The aims and objectives of the Whole Area Testing pilot were broadly met and this evaluation report, with its appendices, provides a comprehensive assessment of the pilot and a potential blueprint for further roll out.

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3. INTRODUCTION

3.1. PURPOSE

The purpose of this evaluation is to assess the planning, implementation and outcomes achieved in the Whole Area Testing pilot against the aim and objectives of the programme and in the context of the changes in incidence of the pandemic. This will inform future potential expansion of this approach to testing as part of our whole Test Trace Protect system, provide learning from experience to other areas both in Wales and beyond who may be considering implementing a similar approach and also contribute to the development of national policy in this area as required.

3.2. PILOT AIMS AND OBJECTIVES

Merthyr Tydfil County Borough was identified during the week commencing 3rd November 2020 as an area that community leaders wanted to explore the potential for mass testing, due to its high prevalence of COVID-19.

‘Mass testing’, or ‘population-level case detection’ (PCD), refers to regular and/or large-scale testing of whole populations defined by area or sector. Rather than testing self-reported, symptomatic individuals, mass testing involves pro-active asymptomatic testing of a defined group; either through universal provision of accessible testing to that group or as a requirement before entering a particular setting1. The Cwm Taf Morgannwg (CTM) Test Trace Protect Service (TTP) had agreed to run a local pilot in its region in two areas – across the county borough of Merthyr Tydfil and in the lower Cynon Valley area of Rhondda Cynon Taf County Borough.

Merthyr Tydfil has a population of just over 60,000 people and the pilot was agreed to run for a three week period, commencing 21st November. It was also agreed by community leaders to pilot mass testing in the lower Cynon Valley area, population of circa 26,000 people, for a two week period, commencing 5th December 2020.

3.3. DEMOGRAPHY OF PILOT AREAS

A breakdown of the population by age group, gender and ethnicity are set out in Table 1 and Table 2 below2:

Table 1: Lower Cynon Valley

Aged 0-15 Aged Aged 65 and over Age All ages 0-4 5-15 16-64 65-74 75-84 85+ Population 1,432 3,326 15,289 2,565 1,630 549 24,791

Gender Male Female All persons Population 12,082 12,709 24,791 Source: StatsWales, Mid-year population estimates, 2019

1 Multidisciplinary Task and Finish Group on Mass Testing Consensus Statement for SAGE, Date: 31 August 2020 2 Ethnicity data is not available at sub Local Authority level for the lower Cynon Valley

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Table 2: Merthyr Tydfil

Aged 0-15 Aged 16- 64 Aged 65 and over All ages Age 0-4 5-15 65-74 75-84 85+ Population 3,658 7,898 37,384 6,399 3,729 1,258 60,326

Gender Male Female All persons Population 29,596 30,730 60,326 Source: StatsWales, Mid-year population estimates, 2019

Number of people Number of people Number of people Percentage of people estimated from a non-white from a white from a non-white background background background 59,800 1,400 58,400 2.3 Source: StatsWales, Ethnicity by area and ethnic group, 2019

The age distribution in the two Local Authorities can be seen below in Figure 1, with some differences across the ages and gender3. When considering the lower Cynon Valley, it is important to note that this will account for a very small proportion of the Rhondda Cynon Taf County Borough.

Figure 1: Percentage of population by age and sex, Merthyr Tydfil and Rhondda Cynon Taf

Percentage of population by age and sex, Merthyr Tydfil Percentage of population by age and sex, Rhondda Cynon Taf

3.3.1. DEPRIVATION IN PILOT AREAS

The Welsh Index of Multiple Deprivation (Image 1) shows that lower Cynon Valley and Merthyr Tydfil have some of the most deprived areas in Wales. In addition, smoking rates are high in both areas (e.g. 22.7% in Merthyr Tydfil) in comparison to the health board average (18.6%) and the Welsh average (17.4%); high levels of overweight and obesity (e.g. Cwm Taf Morgannwg, 63.6% and Wales 59.9%)4;

3 Draft Merthyr Cynon Profile, Local Public Health Analytical Team, CTM UHB 2020 4 National Survey for Wales, 2018/2019 and 2019/20 combined data

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higher prevalence of long term conditions than the health board average e.g. Chronic Obstructive Pulmonary Disease and hypertension3.

Image 1: Welsh Index of Multiple Deprivation (WIMD) 2019, Cwm Taf Morgannwg UHB

3.3.2. BLACK ASIAN AND MINORITY ETHNIC (BAME) POPULATIONS

Anyone who works in or is resident in the pilot areas was eligible for testing. The BAME population of Merthyr Tydfil is 2.3% (n= 1,500)5 and Rhondda Cynon Taf 2.8% (n= 6,700). As an indication of BAME representation in a local keyworker population group, of the 12,018 CTM UHB staff who have recorded an ethnic background, 794 (6.6%) have recorded a BAME ethnic background6, as shown in Figure 2 (below).

5 Data on this item is based on 10 to 25 responses to the survey and categorised as being of low quality. Only estimates of 40 or more responses are considered robust and data items between 25 to 40 responses are categorised as being of limited quality. 6 Pearce A Sept 2020 Cwm Taf Morgannwg University Health Board BAME Staff Profile. Workforce and Organisation Development

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Figure 2: Cwm Taf Morgannwg University Health Board BAME Staff Profile, March 2020.

3.4. EPIDEMIOLOGY OF COVID-19 IN THE PILOT AREAS

The 7 day rolling cumulative cases between July 2020 and 24th January 2021 show a steep rise in cases from early October 2020. This, along with Merthyr Tydfil having the highest rate in the UK with Rhondda Cynon Taf (which includes the lower Cynon Valley) having the 8th highest, was the basis for the decision to introduce Whole Area Testing pilot on the 21st November 2020 – see Figures 3, 4 and 5 below. It can be seen that there was an early September 2020 spike of cases in Abercynon, some of which was associated with high profile local events and travel e.g. Doncaster Races bus trip.

Figure 3: Statistical Process Control (SPC) 7 day rolling chart for positive cases in Merthyr Tydfil (99% CI)

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Figure 4: SPC 7 day rolling cumulative chart for positive cases in Abercynon (99%CI)

Figure 5: SPC 7 day rolling cumulative chart for positive cases in Mountain Ash (99%CI)

Figure 6 (below) shows that in November 2020, Merthyr Tydfil and Rhondda Cynon Taf were the Welsh Local Authorities with the highest rates of COVID-19 in the UK, along with neighbouring Blaenau Gwent.

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Figure 6: Top 20 7-day rolling rates by Local Authority (as of 1st November 2020)

3.4.1. POSITIVITY RATES AND LOCKDOWNS

Figure 7 shows the COVID-19 positivity rates for different age groups identified from 13th September to 22nd October 2020, highlighting higher than the 5% threshold among over 20+ year olds in Merthyr Tydfil and Rhondda Cynon Taf and further justifying population case finding for the whole area7.

Figure 7: Age Specific Positivity Rates by Local Authority

The Wales National Fire Break was effective from the 26th October to the 9th November 2020 and a National Lock down came into effect on the 20th December 2020.

7 COVID-19 age specific analysis by LA, Surveillance Team, TTP, Local Public Health Analytical Team, CTM UHB 2020

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3.5. TESTING STRATEGY

The aims of the pilot were agreed as follows:

1. To test whether or not large-scale testing can yield a significant and sustained reduction in community transmission. 2. To make testing accessible to an agreed area(s) entire population and incentivise uptake. 3. To identify index cases and prevent further transmission through contact-tracing and other measures. 4. To protect those at highest risk. 5. To empower the local community to arrest and reduce the community spread to as low as reasonably possible in order to save lives and save livelihoods and businesses. 6. To identify those who are needlessly self-isolating and empower them to return to usual activities. 7. To assess the impact of testing on behaviour of participant.8

The objectives of the pilot were to:

1. Develop a blueprint for whole town, city, borough or regional testing. 2. Better understand prevalence via asymptomatic surveillance. 3. Develop an intelligence picture and use asymptomatic testing to limit an agreed area’s acceleration through enhanced restrictions escalation. 4. Deploy new technologies in an agile and scalable way.

8 Added post implementation and not stated in the SOP and CONOP

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3.6. HYPOTHESIS TO TEST THROUGH ASSESSMENT OF MASS TESTING

The offering of mass testing, in line with the aims and objectives has a number of potential positive outcomes but also potential for negative consequences. This was identified by colleagues in the Liverpool mass testing pilot, which commenced shortly before the Merthyr Tydfil and the lower Cynon Valley pilot, as seen in Figure 8 (below).

Having regard to this, and to enable some comparisons to be made, this evaluation sought to be comprehensive about the outcomes and consequences. However, it should be noted that aim 7, to assess the impact of testing on behaviour of participant, was not included in the planning and methods for this evaluation. As a result, impact in respect of risk-taking behaviour and population mobility are not elucidated in this report.

Figure 8. Flowchart of potential positive and negative outputs of mass community testing for COVID-199

9 Draft Liverpool Mass Testing- JBC Analysis (8th December 2020).

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4. GOVERNANCE, PLANNING AND IMPLEMENTATION

4.1. GOVERNANCE

This section sets out how the pilot was set up and governed.

Locally Led: Cwm Taf Morgannwg Test Trace Protect – Whole Area Testing Pilot Working Group

With the agreement and support of Welsh Government, the Whole Area Testing pilot was set up and led by the Cwm Taf Morgannwg (CTM) Test Trace Protect (TTP) Service, which reports into the group of Local Authority and Health Board Leaders/Chair and Chief Executives in CTM.

The Senior Responsible Officer (SRO) for the pilot was the CTM Director of Public Health/Chair of the CTM TTP Service. The aim of the TTP programme was to put in place appropriate systems and capacities to ensure that, following the easing of lockdown measures in the first phase, we did not see a rapid increase in illness and deaths in our communities due to COVID-19 infection. The programme includes surveillance, testing, contact tracing, protection of the vulnerable, risk communication and engagement and vaccination work streams.

The Whole Area Testing pilot was set up under a specific working group, reporting to the TTP programme and which operated on a ‘task and finish’ basis. This was usually chaired by the SRO with the support of a senior planner and Deputy Chief Executive, Merthyr Tydfil who also chaired when required.

The working group had clear aims and objectives (as can be seen elsewhere in the document) and members included representation from the two Local Authorities involved, the University Health Board, Welsh Government, Welsh Ambulance Service, Police, Local Resilience Forum, Military and the Third Sector.

The group met daily, including weekends, during the planning, implementation and early delivery period of the pilot project due to the intensity of the work required and tight timescale.

Working in Partnership: Welsh Government

The Welsh Government (WG) established an internal group10 to provide support and consider end-to- end system implications. This included representatives from testing policy, TTP Chief Operating Office, digital, communications, resilience and contract tracing at national level. Public Health Wales (PHW) and the NHS Wales Informatics Service (NWIS) provided support and advice to developing testing protocols and understanding digital requirements.

10 Welsh Government Internal Planning Group (see appendices)

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The Welsh Government’s Test, Trace, Protect (TTP) strategy is designed to enhance health surveillance in the community, undertake effective and extensive contact tracing, and support people to self- isolate where required to do so. Local Health Boards and Local Authorities work in collaboration to deliver regionally co-ordinated local contact tracing teams. This sits alongside their existing roles to provide testing facilities and environmental and public health responses to local outbreaks and clusters or preventative action in areas regarded as high risk. This is integrated with wider partners including Public Health Wales, Welsh Ambulance Service Trust, and the Military and Third Sector11.

Working in Partnership: Military

Working with the Military, both in England and Wales at Welsh Government and Department of Health and Social Care (DHSC) level was key during the initial roll-out of the project. Planning and implementation resources were provided by the Military, following the successful application of two ‘Military Aid to the Civil Authorities’ requests (MACAs) submitted by the Welsh Government.

Working in Partnership: Department of Health and Social Care

As the pilot took place in the context of support from the Department of Health and Social Care in England, both in terms of the provision of equipment and learning from the Liverpool pilot, daily weekday meetings also took place between representatives of the CTM TTP Whole Area Testing pilot Working Group, Welsh Government, the Military and the Department of Health and Social Care to check on progress and resolve issues.

Concerns identified/lessons learned:

The pilot lessons learned log included the need for the following in respect of programme governance:

 Clear, representative working with clear reporting arrangements.  Early statement of purpose, aims, objectives and scope.  Clear accountability and decision-making arrangements.  A Senior Responsible Officer.  Clear policy lead at Welsh Government level as required.

What went well? The following provides observations from the Evaluation Group on what was reported to have gone well in the pilot from a governance perspective:  The governance arrangement was established clearly from the outset and appeared to work well during the pilot period.  Clear reporting arrangements were in place and worked well, including daily meetings for the most part.

11 https://gov.wales/test-trace-protect-html

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 The Military planning resource was very useful and well received, bolstering available resources during the Merthyr Tydfil phase.

What could be improved? Nothing specific was identified in this section.

Conclusions: The governance and reporting arrangements were felt to work well during the pilot.

Recommendations: 1. In establishing Whole Area Testing, it is recommended that a Senior Responsible Officer is appointed to lead and that senior leaders are identified in each partner organisation, including Welsh Government, to form a Steering Group. These leaders should be able to make decisions and allocate resources on behalf of their respective organisations. In addition, specialist communication staff should be in place to support. 2. Regular meetings, daily during critical periods, should be maintained to ensure rapid decision making and good communication. 3. Time should be given to properly define the aims and objectives and plan all aspects of delivery.

4.2. PLANNING

A brief overview of purpose: When establishing the pilot, time was very tight to plan and deliver all the required arrangements. Agreement to run the pilot was reached with local Chief Executives and Leaders in the 1st week of November 2020; the working group was brought together on the 5th November, and a planned start date of 21st November was set for the Merthyr Tydfil County Borough element of the pilot. A subsequent start date for the lower Cynon Valley element was agreed to start on the 5th December.

Methods used: Swift planning and dedicated planning resource to support the delivery of the pilot was key. An early request, made through the Welsh Government, was submitted for three Military planners to assist in the pilot at a local area level in Merthyr Tydfil, at the commencement of the pilot. Resources from the wider TTP programme were added, including support from the CTM TTP senior planner and programme manager.

Each Local Authority set up an Internal Planning Group led by a Chief Officer to co-ordinate the local implementation plans and logistics and to co-ordinate staff deployment for the duration of each phase. Each Group comprised a range of Senior Managers with expertise from across Operational Departments of the Local Authority that had a key role in the delivery of the project including Estates, Procurement, Human Resources, Highways, Finance and Events Officers. Each Planning Group reported to a Senior Leadership Team within each Local Authority to ensure oversight of resource commitments and progress against local timescale commitments, in addition to ensuring effective elected member engagement in the lead up to and during the delivery of the projects.

The senior planner role assisted with the early development of the Concept of Operations, which set out the agreed aim, objectives and scope of the pilot; drafting the Standard Operating Procedure,

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building on a draft, emergent template from the DHSC12; maintaining a lessons learned log13 and pulling together an interim findings report14 from work carried out by the working group.

In planning the pilot, there were a number of critical elements that assisted the set-up. These included the development of the following, although it must be noted that most of these documents were iterative and in development during the course of the pilot due to the very nature of the pilot and this being untested territory in Wales:

 The Concept of Operations15 – setting out the agreed purpose, aim and objectives of the pilot.  A draft template ‘clinical standard operating procedure (SOP) for mass testing for COVID-19 using lateral flow technology’ document, provided by the Department of Health and Social Care as part of the UK mass testing programme4.  The development of a Whole Area Testing Pilot over-arching Standard Operating Procedure16 which included: o A process flow diagram outlining the ‘end to end’ process for community testing17. o The Merthyr Tydfil18 and lower Cynon Valley19 Communications and Engagement plans. o Site Generic Risk Assessment20. o PCR Test Data Privacy Notice21. o Contact Tracing Data Privacy Notice22. o Merthyr Tydfil County Borough Data Privacy Poster23.  The Military planning aide memoir24 which provided a useful ‘handrail’ to operate the asymptomatic test sites. This included guidance on site selection, logistic requirements and working practises.  Maintenance of a ‘Lessons Learned Log’25 26.  The Whole Area Testing Pilot Working Group Interim Findings Report6.

12 The template clinical standard operating procedure (SOP) for mass testing for COVID-19 using lateral flow technology provided by the Department of Health and Social Care (DHSC) under the UK mass testing programme (latest version from WG) (see appendices) 13 LFD Lessons Learned Capture Form (see appendices) 14 Whole Area Testing Pilot Working Group: Interim Findings 14 Jan 2020 (see appendices) 15 MTCBC Whole Borough Testing Planning CONOPS (see appendices) 16 Whole Area Testing MTCB LC – SOP FINAL (see appendices) 17 Process flow diagram outlining the ‘end to end’ process (see appendices) 18 MTCB Communication and Engagement Plan (see appendices) 19 LC Communication and Engagement Plan (see appendices) 20 Site Generic Risk Assessment (see appendices) 21 PCR Test Joint Testing Privacy Notice (see appendices) 22 Contact Tracing Privacy Notice (see appendices) 23 Privacy Notice Mass Testing MTCBC (see appendices) 24 Whole Town Testing (WTT) Planning Aide Memoir (see appendices) 25 WAMT MT- LC-Pilot – Lessons Learned Capture Log draft V3 (see appendices) 26 Lessons Learned Charts and Samples (see appendices)

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Concerns identified/lessons learned: The following sets out some of the planning lessons learned during the pilot, from the lessons learned log:

 Needed daily planning rhythm of working group meetings due to tight timescales.  Useful to have daily rhythm of meetings with DHSC due to tight timescales and innovative nature of the pilot.  Welsh Government handled the successful MACA process and application for Military planning support; this was a positive, swift process.  Need clarity upfront on pilot scope, aims, objectives and timescale.  Need clarity and agreement on target population(s).

 The development of modelling estimates upfront supported the planning arrangements. For example estimates helped inform contact tracing and ‘Protect’ work stream planning and also allow comparison to actuals in due course.  There was a huge benefit in learning from elsewhere to inform the pilot planning and delivery - e.g. it was useful having the template SOP and lessons learned template shared from DHSC, as well as other supporting documentation from the Liverpool pilot.  Process mapping the 'end to end' process was carried out early on and was useful to inform the more detailed planning required. This required iterating as lessons were learned and to accommodate any required changes.  The right siting of locations was important to facilitate population access to testing. This was also reviewed/informed by emerging usage data (geography, Welsh Index of Multiple Deprivation and age group etc.) to help inform further site based decisions.

 Note particularly popular times of the day for accessing testing centres and use this information to help refine workforce and site planning e.g. more people likely to access testing sites after shopping or after school.  Opened one main centre first, then, once staff comfortable with testing process, rolled out to further sites.

 Outreach sites: these proved an excellent way of reaching deprived areas, where many do not have the ability to travel outside of their local communities.

What went well? In terms of planning the pilot, there were several conditions fundamental to successful Whole Area Testing which were gleaned from lessons learned elsewhere, particularly from the pilot being held in Liverpool, and which were built into the planning, including:

 Extensive integration with Local Authorities to co-design testing in each area, ensuring a focus on an end-to-end whole system.  Comprehensive communications and engagement plans.  Good workforce planning to ensure sufficient workforce of the correct balance and qualification.  Testing capabilities in the right place, on time and in sufficient number.  Policies in place to facilitate: - Testing to release contacts from self-isolation - Compensation for lost revenue

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 Lessons learned logs were maintained throughout the life of the pilot project, which helped inform delivery along the way and the evaluation.  An evaluation framework established, to include: - Behavioural insights - Operational experience - Success of partnerships - Assessment of impact and effectiveness

What could be improved? The pilot had to be set up, planned and delivered in a short-timescale. In other projects, a slightly longer timescale may be required to establish such a LFD testing service, particularly if there is no additional planning resource to enable the accelerated implementation that took place in this pilot.

Conclusions: On balance, despite tight timescales the planning of the project is thought to have gone well, particularly with the boost from the Military and TTP planning resource brought in at relatively short notice to support the pilot.

Recommendations: 1. Securing a planning resource and adopting a project management approach to such a project (including lessons learned) is key. 2. Ensure that the planning focus is on the development of an end-to end-pathway, from the point of accessing the testing, all the way through to results received, contact tracing and self- isolation support where required. 3. A good communications and engagement plan underpinning this work is critical to ensure good community awareness and attendance. 4. Ensure a focus on lessons learned and project evaluation at the beginning of the project. This will help the implementation of the project along the way and also secure the right resource and agreed approach as to how the project results will be captured, evaluated and shared. 5. Depending on the context and type of LFD testing service being established, some of the lessons learned above may provide useful recommendations for consideration in setting up a similar service elsewhere.

4.3. IMPLEMENTATION

Implementation of the pilot was very much locally led and driven. There was excellent leadership from both Local Authorities involved, from the Leaders and Chief Executives to senior officers and officers on the ground. Particular mention should be made in both areas to the dedication and hard work of all teams pulling together to deliver a challenging pilot in terms of logistics etc. in such a tight timescale. For many staff this was in addition to their ‘day jobs’ and involved working seven days a week for the planning and implementation periods.

In Merthyr Tydfil area, implementation was very much led by the Local Authority in partnership with the Military. A second MACA enabled the deployment of an additional 155 Military personnel. The Military personnel were split into two cohorts. Cohort one (96 Military personnel) were employed as

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testers, cohort two (59 Military personnel) were employed in supporting roles such as command and control, logistics, and force health protection27. This workforce deployed to support the delivery phase allowing the Local Authority time and space to recruit a civilian workforce and open the additional testing sites. Just to reinforce, the Local Authority staff established the first main testing centre at Merthyr Tydfil Leisure Centre (also known as Rhydycar), on time and with a professional set-up. The Military deployment involved augmenting the personnel from Military units from across the UK; many had come straight out of basic training. Once arrived in Wales, they had to be fully briefed on the task and orientated to the environment they would be working in. This process will always take a few days however, once on task Military personnel added the capability to facilitate the further roll-out of the pilot to other centres across the borough.

In the lower Cynon Valley, where the pilot commenced two weeks later, this was led at local level by the Local Authority, who also sourced all of the staff at a local level to run their testing centres. Rhondda Cynon Taf Local Authority set up a project team, led by a senior officer, who took this work forward from local planning, through to implementation and collation of local lessons learned, which were added to the pilot lessons learned log.

Concerns identified/lessons learned: In terms of lessons learned during the implementation of the pilot, Figure 9 shows the proportion of lessons learned for each area (e.g. site set up):

Figure 9: Merthyr Tydfil and the lower Cynon Valley - lessons learned

27 The principles of force health protection are - manage the workforce; ensure correct spacing between personnel; stagger shifts and mealtimes; touch-free handles and interfaces.

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This provides a sense of where some of the major challenges are, as can be seen detailed elsewhere in this evaluation report under the relevant sections. The lessons learned log also provides further details, which are not repeated here.

What went well? The second MACA secured the deployment of 155 Military service personnel, broken down as previously described, to support the Local Authority deliver the project in the Merthyr Tydfil area. The Local Authority HR team developed a plan to integrate the Military personnel, which would be followed by their gradual transition from Military supported operation to an operation fully staffed by a civilian workforce by 7th December 2020.

It should be recognised here that Merthyr Tydfil County Borough Council had established the main testing facility in Merthyr Tydfil Leisure Centre and had started testing prior to the 155 service personnel arriving. The arrival of the additional Military personnel were a force multiplier enabling Merthyr Tydfil County Borough Council to open the additional smaller sites, whilst training the follow on workforce.

Due to the constraints contained within the MACA, the Military personnel were not remitted for deployment to the lower Cynon Valley testing locations. Rhondda Cynon Taf did an excellent job developing their own rollout based on the learning and observation from the Merthyr Tydfil pilot. The lower Cynon Valley pilot should be seen as a good practice model without Military assistance for future rollout of community testing across Wales.

In both areas, it was clear that there was the development of excellent team cohesion. The teams that have worked together, moving from site to site ‘gelled’, and as one team leader was reported to have noted, ‘they have become more than a team, they feel like a family’. A senior Military colleague commented ‘it is pleasing to see strong effective leadership within a civilian workforce that is willing to empower their staff, and equally important to see staff empowered and embracing the opportunities. This is also a recognition that they are playing their part in a pivotal moment in history. One person told me they studied mass testing during their university studies, and now they were part of one and extremely proud to be’.

Many team members were noted to have embraced their new roles and learned new skills, which will benefit them for future employment opportunities. They have also become very proficient at the testing process and protocols.

What could be improved? Similar to planning, the pilot was able to be up and running in a very short timescale, with the benefit of additional resources in Merthyr Tydfil in the form of additional Military personnel supporting implementation ‘on the ground’. Where such resource is not immediately available, a slightly lengthier timescale to implement may be required whilst staff are identified and redeployed and/or recruited as necessary. Good workforce planning is essential in this respect together with pragmatic and comprehensive training plans to enable staff to ‘hit the ground running’ as swiftly as possible, with good support.

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Conclusions: Implementation of the pilot was the most challenging and labour intensive part of the whole process as might be expected. Good leadership, excellent team work and positive partnering with the Military made this a successfully implemented pilot, set against the backdrop of tight timescales and being new to Wales in nature.

Recommendations: 1. It is recommended that in terms of the implementation of similar projects, the Lessons Learned Log is considered, as this provides a range of learning and experience across a wide range of areas experienced during the pilot.

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5. LOGISTICS

This section describes the process of establishing testing sites within the pilot areas, and the associated wrap around community support. It is acknowledged that workforce (including training) is a key part of logistics, and this is focussed on within section 5 of this report.

5.1. COMMUNITY BASED TESTING

A brief overview of purpose: A key objective of the Whole Area Testing was to pilot an end to end process at venues where PCR testing was also available (namely at Merthyr Tydfil Leisure Centre, Aberfan Leisure Centre and Mountain Ash Bowls Centre). The aim was to secure rapid follow up PCR test for those with a positive LFD test, followed by engagement with Contact Tracing Service staff on site, and referral to support organisations as required to enable self-isolation for cases.

Those eligible to access to the Whole Area Testing pilot included those:  Who live, work or study in Merthyr Tydfil County Borough or the lower Cynon Valley area of Rhondda Cynon Taf County Borough.  Who are 11 years of age, or over.  Are asymptomatic.  Who consent to participation in the pilot.  Who consent to sharing their data with the Welsh Test Trace Protect service  Children aged 11-17 for whom appropriate consent is obtained and where testing was done at a community venue, with the child accompanied by a consenting parent/guardian. 11-17 year olds will self-swab with adult supervision.

Methods used: The Local Authorities already had structures in place to plan for the establishment of testing sites, to include:

 A Command and control node and communications network. A very experienced and proven team that had already dealt with heavy snowfall, flooding and a recent COVID-19 shielding plan. In Merthyr Tydfil, they were also very supportive of the Armed Forces, embracing the ideas generated by the Military planning team.

 Highways department - dealing with route signage, road closures, traffic calming measures etc.

 Waste collection - including clinical waste protocols in place for Care Homes.

 Leisure Centres - these sites came with a potential workforce, with similar skills required such as receptionists, cleaners, public focussed staff, and known by the local population.

 Estates legal team - experienced in writing business interruption contracts.

 Human Resource (HR) and Training team - to hire suitable staff, and train trainers to deliver and assure any training. The HR team would also manage the daily workforce requirements, including the Mobile Testing Unit once deployed.

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 Construction/Maintenance Team - this team would build and maintain the testing sites.

 Distribution hub and supply chain with storage for the PPE and Test Kits, including a reverse supply chain to manage an effective stock control process.

 Utilisation of the Local Authority polling station plan, which included a quality & assurance team that inspected and assured all sites prior to opening.

Across both pilot areas (Merthyr Tydfil and the lower Cynon Valley), the proposals were based on a Hub and Spoke Model with each Local Authority area having a main testing venue for the duration of the programme, with additional community (spoke) venues deployed in phases.. A summary of where those sites were and their estimated testing capacity figures is included in the Interim Findings Report6.

In Merthyr Tydfil, the planning product was delivered in 3 phases.

 The Local Authority led and managed all testing sites.  A detailed synchronisation matrix gave clarity to the plan.  The Military Testing Team deployed in support and extracted as early as possible once the follow on trained civilian workforce was in place.

In the lower Cynon Valley, only phases 1 and 2 above were relevant.

To determine throughput at each testing site, modelling estimates (informed by the Liverpool pilot) were calculated for the numbers of daily tests and subsequent stages of the end-to-end process. As the roll-out of testing centres progressed, the working group used intelligence coming from those tested to inform their agreed subsequent location of sites, in particular to reach the more deprived areas, where data was indicating that uptake was lower, and also to inform the pilot communications campaign where the data was also indicating that younger people, especially younger adult males, were proving more difficult to reach.

The key stages of the end to end process are summarised below:  Stage 1 – Lateral Flow Device testing  Stage 2 – PCR testing  Stage 3 – Contact tracing  Stage 4 – Protect

The end to end process is illustrated in full detail within the diagram below (see Appendix 17 for a more detailed view).

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5.1.1. HOME TESTING ARRANGEMENTS

Arrangements were made for those identified in the area as shielding previously during the first COVID-19 incidence ‘peak’ in April 2020, to receive a home test kit. Home test kits were mailed out from the DHSC to everyone on that shielding list. The Local Authorities provided their lists in a secured format to DHSC who mailed out one PCR test kit to each shielding person. Each person was advised to either use a priority mailbox to return the kits, or where they were not able to do so, to ring 119 to arrange a courier pick up. There were a reasonable number and distribution of Royal Mail priority mail boxes across the pilot areas.

For those who are disabled, or unable to leave the house for any reason and were not on the vulnerable/shielding list, a home visit to deliver a PCR test was offered to the individual (not to the whole household), if requested. This was a self-administered PCR, processed via Public Health Wales Laboratories.

In the lower Cynon Valley an initial phone call was made to those shielding in an effort to explain the process and secure greater uptake.

5.2. CONTACT TRACING

As LFD results did not flow into the Contact Tracing CRM, a bespoke online tracing form was created for use in the pilot. This allowed cases to be traced using the same script as the national Contact Tracing Service, with results flowing into a separate system for analysis and management of contacts.

On the first weekend of testing at Merthyr Tydfil Leisure Centre, cases that returned for a PCR test were offered three tracing options, namely:

Option a) Complete an online form with a Contact Tracer on site. Option b) Provide a contact number for a Contact Tracer to call them and Trace later that day. Option c) Provide an email address for receipt of the online tracing form link and complete a self-trace as soon as possible. All cases in the first weekend chose Option c, however none completed the online form.

On Monday the 26th November, the decision was made to only offer Option a, in order to increase the positive engagement with the Contact Tracing element of the pilot. Contact Tracers were withdrawn from Aberfan Leisure Centre on Wednesday 28th November as only one case had returned to site and submitted for contact tracing. Contact Tracers remained on site at Merthyr Tydfil Leisure Centre and Mountain Ash Bowls Centre for the duration of the pilots.

During the Pilot, 414 cases submitted for face to face contact tracing having returned to a testing centre to undertake a PCR test. This total consists of:

 243 cases in the Merthyr Tydfil phase  171 in the lower Cynon Valley phase.

For the 414 cases who completed a contact tracing interview on site, 1,063 contacts that needed to self-isolate were identified. There comprised:

 819 household contacts

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 244 other close contacts (e.g. workplace/ social contacts)

On receipt of the PCR test result,

 21 people were found to be negative and they and their contacts were released from isolation.  All cases confirmed as positive by PCR were followed up again by the Contact Tracing Service to validate the previous information obtained on site, to confirm to all contacts the need to complete the self-isolation period and to re-visit any support required to enable cases and contacts to complete their self-isolation period.

The significant majority of cases that were followed up on site at mass testing centres were traced within 2 hours of their LFD result. Tracing undertaken following PCR only is not typically initiated until 24-48 hours after laboratory confirmation is received.

5.3. PROTECT

Ensuring high levels of adherence to the need to self-isolate in response to symptoms, a positive test for COVID-19 or having been contact traced is fundamental to the success of the overall Test Trace Protect programme. It is recognised that people will face different challenges in successfully self- isolating, potentially on more than one occasion.

The strategic aim of the Protect work stream is to identify the support which may be required by some people to enable them to successfully self-isolate and ensure this support is provided openly and equitably across CTM.

A Tactical Group met weekly to exchange intelligence, guidance, information and update on supply of and demand for community support for people to self-isolate following a positive test result or being contact traced. Members of the group represented: • Cwm Taf Morgannwg Regional Partnership Board (Work stream Lead and RPB Chair) • Interlink (Community Voluntary Council (CVC) for Rhondda Cynon Taf) • VAMT (CVC for Merthyr Tydfil) • BAVO (CVC for Bridgend) • Rhondda Cynon Taf CBC • Bridgend CBC  Merthyr Tydfil CBC • Head of CTM RPB Commissioning Unit • Public Health Wales • CTM Public Health Team • Research, Innovation and Improvement Hub Team members • CTM UHB • CTM Public Service Board Support Team

A range of support was made available and has been provided to individuals who have faced challenges during ‘lockdown’ and through periods of self-isolation. Local Authorities, in partnership with the Third Sector and Volunteers, have helped people with shopping, collecting medicine, loneliness and isolation, emergency food and support and a very wide range of other support needs.

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During the Whole Area Testing pilot, the following activity took place:

 Working with Merthyr Tydfil County Borough Council colleagues, VAMT introduced a model of support at the beginning of the pandemic. This model included brokering connections to Third Sector partners and community organisations to support community members with e.g. shopping services, prescription collections, food parcels and befriending. This model was still in place during mass testing.

 Rhondda Cynon Taf County Borough Council carried out a discrete piece of work with Schools, Services, and medically vulnerable residents in the area by contacting those previously on the Shielded Patient list (SPL) and vulnerable residents in the lower Cynon Valley pilot area to support the Whole Area/Community Testing effort.

 Residents previously on the SPL in the lower Cynon Valley pilot area received a supportive telephone call to alleviate any anxiety and to provide information in relation to the process of receiving and returning Home Testing. This call also enabled the capture of a baseline of information about their intention to take the test when received or not.

5.3.1. CWM TAF MORGANNWG (CTM) SELF ISOLATION HELPLINE

A new Self Isolation Helpline (SIH) launched in November 2020 was available for anyone testing positive or those traced as a contact. A rapid collection of softer intelligence on COVID-19 beliefs and attitudes in CTM had been undertaken, collating feedback from backward contact tracing activity and anecdotes shared by members of the RCCE and Protect Tactical Group. This intelligence supplements the epidemiology and cluster intelligence considered by the CTM Regional Incident Management Team (RIMT).

The findings indicate that there was considerable confusion about self-isolation and the availability of support particularly for contacts and many unanswered questions, all of which lead to non-compliance with COVID-19 measures. This highlighted the need for ready access to reliable information, communicated in person at the right time.

The helpline provides:

- A way back into the Contact Tracing team (CTT) service to answer the questions that COVID-19 cases and contacts may have

- Another opportunity for people to be sign-posted to local support that will enable them to follow the self-isolation advice received

SIH Operation Principles:

 Rhondda Cynon Taf County Borough Council host the Regional Contact Tracing Service on behalf of the three Local Authorities (Rhondda Cynon Taf, Bridgend and Merthyr Tydfil). As an extension to this, Rhondda Cynon Taf set up and hosted a 7 day a week Contact Tracing Helpline available to residents across Cwm Taf Morgannwg.

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 A single contact number (Rhondda Cynon Taf Contact Centre 01443 425020) takes calls from across CTM. This number cannot be included on the nationally agreed automated “texts” that cases and contacts in CTM receive from the CT service. Therefore, a separate CTM text is sent to cases and contacts containing the contact centre number for further advice/ information.  The Rhondda Cynon Taf Contact Centre number is included on letters sent to contacts who do not respond to telephone calls.  The helpline signposts individuals identifying as needing support to a single point of contact provided by the community co-ordinator in each locality who is available Monday to Friday.  The community co-ordinator assesses need and links individuals with local assets as appropriate (directly delivered, commissioned services and Third Sector organisations).  Two-way signposting arrangements between the locality support and the regional contact tracing helpline exist. The locality support providers are enabled to deliver consistent messaging to people who already present to them for information assistance or advice armed with key messages and FAQs.

Concerns identified/lessons learned: The following summarises some of the main logistics lessons learned during the pilot. These are taken primarily from the lessons learned log (which may be of assistance to others considering the adoption of a similar approach) and from the experiences of the community support arrangements established across the pilot areas.

Site set up  Site recces / plans / set-up should be undertaken with joint involvement from departments across the Council, including Events (and possibly Design for the signage), Corporate Estates, Cleansing and Leisure (especially Site Managers who will be overseeing the events at that particular site). This will allow for a greater sharing of information and perspectives, where an action log and timescales can be set, therefore minimising issues and the need for any future changes.  Site visits are essential to walk through the proposed process prior to the centre opening and helps with contingency planning, stress testing the system etc.  It is critical to have a plan of the site layout prior to set up showing both layout and intended flow of public through entrance and exit points. This will speed up signage and the placement of arrow markings and distancing advice.  Signage on site is vital - clear and relevant, together with well-informed stewards etc. who can assist with queue management, queries and keeping the public informed at all times.  Ensure key posters displayed as required to assist in informing the public whilst at the testing centre e.g. data privacy notice and how to register online while waiting if able to, with a smart phone.  Be prepared for members of the public turning up early, prior to opening times for tests, especially on day one.  Need to have the site manager and key holder information circulated prior to build to allow access to the sites as early as possible.  Better to have more space inside to queue people especially during inclement weather.

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 Mobile devices need to be logged in the day before to ensure sites are registered and there are no issues with connectivity and devices charged. Cleaning and waste management  Check the testing venue before opening to establish if seating on site is suitable i.e. not fabric covered and can be sanitised and wiped over.  Ensure that all booths, chairs, tables and set up materials are sanitised following final closure of sites. This will mean sites can be dismantled immediately rather than wait for 72 hours.  Safe systems of cleaning documented – clearly understand what cleaning materials are required to fulfil sanitising requirements on site, clinical waste systems adhered to.  Ensure the correct disinfectants are used, advice will be provided by LAs environmental health teams. This is tied in with having an adequate cleaning regime including high touch points and removal of contaminated waste.  Need to ensure clear and agreed waste management processes with clear and agreed waste management policy including commissioning of sub-contractors where necessary.

Clinical

 Testing process needs to be clear early in planning to inform logistics etc. The early decision made the by working group to do confirmatory PCR for those LFD positive cases, preferably on-site, assisted with logistical and workforce planning.  Need to ensure laboratory capacity can cope with demand - additional Public Health Wales laboratory capacity required for confirmatory PCR test.  Ensure that any WAST staff on sites, (undertaking confirmatory PCR tests), are tested on site each day and adhere to the same rules around social distancing etc. as Council mass testing staff.  Choice of PPE new masks: elastic not comfortable.

Data capture

 One source of data per site to avoid confusion / inconsistency with numbers – reports at 1400hrs and 1930hrs to key contacts – leading to reported numbers at 2000hrs daily.

Digital

 IT: important to have prior knowledge of: details around the system and the application itself, Carrier (Vodaphone), Connectivity (4G), the on-boarding process - codes etc., the end to end process (burner mobiles etc.). This would have saved a lot of legwork on site/device/investigation suitability and meant it would have resulted in boosters etc. earlier in the process.  Network boosters were needed especially in outreach centres. Difficult at times to get a phone signal at some locations.  Each site needs a dedicated "burner" phones, (doesn’t need to be smartphone), to use for results for those who do not have a mobile number.

 Tablets with cover rather than a phone for registration would have worked better.  Ensure manual back-up processes are in place where required and essential, if digital processes fail for any reason.  Need to ensure have a plan for those with no phone or email address.

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 Expect issues with people not being sent their results due to phone networks etc.

 Clarity from NHS app updates - updating with no knowledge.

Engagement and communications

 Despite clear messaging on asymptomatic people only attending ATS, assume some symptomatic people will unfortunately still do this. Ensure mechanisms in place for identifying such people as soon as possible and re-direct them to an appropriate test site.

 Information leaflet for those arriving at ATS site deemed too bulky so being redesigned. Bear in mind individuals have to hold barcodes, registration card and leaflet.

Site operation

 Highways - inspections to be carried out prior to opening to identify and rectify any trip hazards – e.g. carriageway potholes, footway defects etc.

 Portable Electronic Devices (PEDs) – There were sufficient stocks of PEDs however the operating applications changed regularly without prior notification. The agility of the workforce quickly adapted to the ever changing situation, the drawback was small delays in the registration process, which is a long enough process anyway, the outcome were queues building up, which in turn turned off a proportion of people from getting tested.

 LFDs – These need to be available during the training phase to help the workforce understand the process. The workforce also need enough for their daily testing, which needs to be started at least 1 hour before the site opens.

 Bottlenecks - registration is a severe bottleneck, queue managers and registration assistants are vital to managing flow into testing room. Staff here need good communication skills, ensuring that once registration forms and barcodes are provided, public can self-register to speed up process.

 Have to ensure adequate breaks for staff, catering facilities should be considered where possible.

 Spare barcode utilised with result-to prevent the need of a second test if result not delivered.

 Registration process was long winded. Staff registering people felt that the masks worn hampered what they could hear and some older people were being asked 4 or five times to repeat themselves. A section on the registration card that people could fill in names, mobile number, post code etc. would help this process.

 Inventory audit at the end of each day possibly, to ensure all equipment is accounted for. Signage may become damaged, etc.

Transport

 Consider during planning alternative support for positive cases travelling home on public transport if they do not have PPE. Best practice/solution may have been identified elsewhere.

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Protect

 During the Whole Area Testing pilot period, calls to the Helpline increased by 29.5%. There was a 56% increase in calls relating to self-isolation financial support.

What went well?

 The co-operation between agencies was impressive: Welsh Government; Health Board; Local Authorities; South Wales Police; WAST; Test Trace Protect; Military and Third Sector organisations.  Each Local Authority led and managed the centres and identified staff to oversee logistics. For example, site managers maintained a daily stock level based initially on estimated throughput, and adapted to changing resource requirements.  A simple WhatsApp communications network was established to manage resources throughout the day  Booths not provided from day 1 – Merthyr Tydfil Council Borough Council had alternative, adapting the use of polling booths for the testing booths was a measure forced onto the decision process due to the difficulty around securing the official booths provided by Deloitte. Not sufficient however for all sites.

Without the flexibility of thought and use of initiative the pilot may have failed before it started. This has been adopted as best practice across other Community Testing schemes.  Always have a contingency plan - significant contingency plans were needed at the beginning of the pilot as: - Barcodes did not arrive from DHSC on time. These were delivered as part of the PPE pack, a clear weakness in the supply network. This became evident when the initial PPE delivery was delivered to the wrong location. The pilot could have commenced without PPE (LA had its own supply) but the barcodes were a critical part to the testing process. Barcodes had to be obtained from 2 x PCR testing sites in Ebbw Vale & Abercynon, although these were different barcodes they allowed the pilot to commence on time. The drawback was managing the change over to the correct barcodes when they arrived, as inevitably the wrong barcodes kept reappearing for a short period – this affected data collection. - Military resource did not arrive from day 1 (except Military planners) to help the initial site. - Trainers from DHSC did not arrive from day 1 to 'train the trainers'.

Despite the above alternative arrangements were found and the 1st centre opened as planned to the credit of the Local Authority.

Protect  The potential inability to meet the demand given the limited resources. However the early pandemic model implemented proved successful and during mass testing community partners reported a belief that individuals that had previously been brokered were continuing to be supported by them.

 VAMT with Merthyr Tydfil County Borough Council and Community Partners including Registered Social Landlords’ had set up a Merthyr Tydfil COVID-19 Steering Group which continued to meet and information from the group was used to inform the mass testing process.

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The ability of the Third Sector to respond flexibly to meet the needs of individuals testing positive for COVID-19, as well as those having to self-isolate as a direct result of being in contact with a positive case. The well-established and effective co-ordination and brokerage of support continued by Community Resilience Hubs and through Interlink’s Community Co-ordinator service.

What could be improved?  Data ownership so that the LA can quickly react to potential COVID-19 hotspots.  Generating a dedicated testing team. This team would be specifically recruited to conduct LFD testing, this would release any staff that have been redeployed to fulfil the requirement. This would enable a longer term solution and minimise staff burn out, particularly if that member of staff was also conducting the duties of their primary role.  The ratio of hubs to mobile stations should be carefully considered having regard to population density, accessibility and topography of the relevant communities. The range of one hub for 20,000 – 40,000 population depending on these factors is realistic.  Flow of LFD results into the National Contact Tracing CRM system would have enabled easier case data management and contact follow up.  There were a number of digital issues encountered, as described in the concerns identified/lessons learned section, above. Consideration of these for future planners, will help improve smooth operation at testing centres

Conclusions: A robust logistical plan is essential to a smooth operation, ensuring the following 5 principles are considered:

1. Foresight – The ability to predict and take or manage risks, this becomes particularly important when resource levels are reduced without a commensurate reduction in tempo. 2. Efficiency – achieving the maximum level of support for the least effort, in order to make best use of finite resources and the supply network. 3. Simplicity – enables plans, systems and organisations to react well to the unforeseen, ensuring the plan is easily understood. 4. Cooperation – helps share logistic responsibilities and resources allowing the workforce to interact efficiently. 5. Agility – allows a team leader the ability to respond quickly to the unexpected, remain effective under difficult conditions, allowing flexibility to overcome the unforeseen.

The plan was understood by everyone involved and was easy to communicate to the public, which ensured a high take up. Key benefits were:

 The simplicity of the plan to enable the roll out to other Local Authorities.  The inclusion of secondary schools in the pilot, which has helped to inform the roll out of testing to schools.  Onsite contact tracers ensured cases received correct advice on self-isolation and allowed household contact advice to be given. It also facilitated rapid follow up of cases associated with complex settings such as workplaces.

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Having a dedicated Protect resource in the Community Co-ordinator to help partners/ community members to navigate the 3rd sector has been crucial at a time when an immediate/ emergency response has been required. Subsequently the model of support is keeping people safe, well and supported in a community setting rather than them having to access more costly statutory services. Notwithstanding the current level of support available to deliver community led action and Third Sector services, there is a significant risk to this provision in the long term due to short term project funding of community resilience work and a strategic approach, with adequate investment, to bolster community led preventative work to address the growing and worrying increase in poor mental health as a result of COVID-19 restrictions.

Recommendations: 1. Provide home testing kits for those that test positive (7 day supply). 2. Consider at an early stage if Military support is required, and request for a Military Advisory Team (MAT) initially, that can inform whether additional Military support is required either for planning or delivery purposes. 3. Protect - The re-introduction of borough wide or regional resilience planning to strengthen the connection between co-ordinated volunteering and the redeployment of staff across sectors in an emergency situation would be welcomed.

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6. SCHOOLS BASED TESTING – MERTHYR TYDFIL28 AND LOWER CYNON VALLEY29 A brief overview of purpose: Testing was established in schools based settings – this included 6 secondary school settings, a special school and a pupil referral unit in Merthyr Tydfil County Borough, and in one Secondary School in the lower Cynon Valley area of Rhondda Cynon Taf County Borough. There were different approaches to the pilot taken in each area. Merthyr Tydfil benefited from support provided by the Military, both in terms of planning and implementation of the Whole Area Testing pilot. The lower Cynon Valley team were fortunate to learn key lessons from the various approached to testing delivered in the Merthyr Tydfil schools, and this enabled them to design and deliver their own workable testing regime at the secondary school.

In reading this section of the report, it should be noted that the learning and approaches taken were different in different areas and different schools. The style therefore, reflects these different approaches and the learning identified.

Merthyr Tydfil County Borough was identified during the week commencing 3rd November 2020 as an area that community leaders wanted to explore the potential for mass testing, due to the high prevalence of COVID-19 in this area. Merthyr Tydfil has a population of just over 60,000 people and the community-based pilot was agreed to run for a three-week period, commencing 21st November 2020. It was later agreed by community leaders to pilot community-based mass testing in the lower Cynon Valley, with a population of circa 26,000 people, for a two week period, commencing 5th December 2020. This area also had consistently high prevalence rates. The time period to commence testing in schools were agreed as:

- Merthyr Tydfil County Borough – Monday 30th November 2020 - Lower Cynon Valley - 7th December 2020

Additional work was also undertaken separately, looking at the risk of transmission in schools in Cwm Taf Morgannwg. The relevant findings are included in this report to provide context. The review of school cases30 suggests that:  Approximately half of cases can be accounted for by community acquisition, mostly from a household member index case.  Where cases are identified in a school setting, they are usually associated with smaller social/friendship groupings both inside and outside school.  Remaining cases could not identify a clear source of transmission. There is no clear evidence of wider in-school transmission, outside of these smaller social/friendship groups.

28 Afon Taf High School; Bishop Hedley RC High School; Cyfarthfa High School; Pen-y-Dre High School; Ty Dysgu Homfray; Greenfields Special School 29 Mountain Ash Comprehensive School 30 The Schools Review can now be found on the CTM main COVID-19 page (it’s right above the “Calling all staff” box) https://cwmtafmorgannwg.wales/latest-information-on-novel-coronavirus-covid-19/ You can also access the Reviews directly with these links (if you needed them): (English Version) (Welsh Version)

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 Case rates in schools reflect prevailing rates in the community. It was noted that cases increased towards the end of the autumn term, in line with increases in community incidence.  Overall, cases as a proportion of all pupils and staff, and contacts per case, remained low, indicating effective control measures were in place.  There is a high degree of confidence in compliance, in the main, with effective engagement of the education sector including the Local Education Authorities, schools and pupils.

Methods used: The mass testing was led under the auspices of the Cwm Taf Morgannwg (CTM) Test Trace Protect (TTP) programme and locally delivered by the Local Authorities – Merthyr Tydfil County Borough Council and Rhondda Cynon Taf County Borough Council; Cwm Taf Morgannwg University Health Board; the Third Sector and other supporting partners.

Testing sites were established in both the community and schools, enabling anyone (aged 11 years or older) living or working in the areas to have a LFD test. This section of the report focuses on schools- based testing which was undertaken in the following settings.

Merthyr Tydfil County Borough:  Afon Taf High School – roll numbers 771  Bishop Hedley RC High School – roll numbers 583  Cyfarthfa High School – roll numbers 1,024  Pen-y-Dre High School – roll numbers 770  Ty Dysgu Homfray – roll numbers 20  Greenfield School – roll numbers 171

Lower Cynon Valley area of Rhondda Cynon Taf County Borough:  Mountain Ash Comprehensive School – roll numbers 1,061

Other pupils residing in the lower Cynon Valley area, but attending other schools (Welsh medium school, Pupil Referral Unit, faith schools) were invited to attend the community testing centres. Children with special educational needs were sent a home test kit or advised to attend the testing centre if possible.

6.1. COMMUNICATION AND ENGAGEMENT

It was determined as essential at the outset to ensure the successful delivery of the pilot. Regular meetings were held with Head teachers, Chairs of Governors and the relevant Director of Education. Communication with parents/carers was extremely important, and included, for example, a Frequently Asked Question (FAQ) on the Rhondda Cynon Taf website, and school messaging services were used to disseminate information and send reminders. Within Merthyr Tydfil, the Learning Department and schools communication with parents was vital so that they were able to make the choice of having their child/ren tested within school.

By facilitating this within the schools, it was evident that schools would be able to have a closer focus on the volume of pupils actually being tested. As a result of this, it would allow schools to manage the wider school community in relation to attendance and well-being of staff and pupils. Letters to parents/carers included an explanation of the testing process and consent forms.

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A key message to improve communication further must include a demonstration video for parents to view, which graphically demonstrates the testing process. This would have alleviated concerns of parent with low levels of literacy, reduced anxiety and increased take-up.

6.2. SECONDARY SCHOOL MASS TESTING – MERTHYR TYDFIL31

The education of our children and young people is likely to have been adversely impacted upon by schools being closed for 3 months during lock-down and continued year group closures due to isolation. The aim is to keep schools open and to engage as many pupils and staff as possible throughout the course of the COVID-19 pandemic32.

Education outcomes are a priority, and this is where the mass testing of secondary aged pupils (11- 16) has been critical, in order to ascertain if the school environment contributes significant risk in the transmission of COVID-19 and to assess the number of positive cases identified.

Staff and pupils in Merthyr Tydfil schools were offered two tests on consecutive weeks.

Methods used: It was critical that the Learning Department recruited the correct members of staff from schools to lead on the delivery within their respective locations. Schools were then expected to quickly identify volunteer staff from within their locations and the LA to assist colleagues in schools for a successful roll out of this initiative. By working together, it has empowered all stakeholders to play a collective role within this vital piece of work.

Two staff members from the Learning Department had been identified for their skill set, it was imperative to quickly establish a system of working and implement a timeline of events for key stakeholders at the forefront. The Learning Department Support Team, proved essential in their support, delivery, advice and commitment.

Each school was instructed to find a suitable location within the school’s premises for testing, and then requested to produce procedural documents. From the outset, the Chief Education Officer (CEO) and identified Learning Department Support Team were heavily involved with school Senior Leadership Teams (SLT) to ensure that all processes were formulated in accordance with expectations. The Learning Department Support Team were responsible for co-ordinating delivery of sufficient stock to each school based on pupil and staff numbers, within a quick turnaround, due to time constraints. This was to ensure that the schools could operate this initiative with minimal risk on the narrow margin of identified testing days.

The Learning Department Support Team devised an Excel recording/monitoring record, in order for schools to capture their log for the days of testing. This was developed as the schools were not being provided with equipment to scan barcodes. On receipt of the Excel record, schools were able to pre- populate pupil and staff information to alleviate any additional pressures on school support staff at the commencement date of testing. Two schools were innovative in their thinking and devised their

31 Afon Taf High School; Bishop Hedley RC High School; Cyfarthfa High School; Pen-y-Dre High School, Ty Dysgu Homfray, Greenfield School 32 MTCBC Mass COVID-19 Testing (see appendices)

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own ‘in house’ applications over the course of a weekend to read barcodes electronically, therefore further reducing the stresses of support staff and human error.

The Learning Department Support Team had a final meeting with school SLTs before Monday 30th November 2020, roll out.

From the outset on the morning of the 30th November 2020, the LA support staff attended all secondary schools in order to attend briefings before the commencement of testing. This was imperative to show support to all staff assisting and allowed LA officers to ensure that due process was implemented. The school visits continued throughout the course of the day. Stock was continuously monitored and replenished where identified as needed. Learning Department Support Team met with the Chief Education Officer on school sites to view the good working practices applied. A debrief took place at the end of each working day, between the Chief Education Officer and Learning Department Support Team to discuss any concerns that have arisen during the day.

Concerns identified/lessons learned:

Supply/logistics  Day two of testing saw a reduced number of staff from the Health Board, but Learning Department Support Team had trained additional LA support staff to take their place so that a full complement could be provided to schools.  Schools were not provided with equipment to scan bar codes.

What went well?  Learning Department Support Team established contact with school support staff to ensure they were familiar with their continued responsibilities for day three of testing, where needed, and checked their well-being.  Learning Department Support Team visited all schools and additional stock delivered to the schools; stock check undertaken for the following day.  At the end of the first week of testing in secondary schools, feedback was sought from schools to identify any matters arising from week one. In addition, schools were also briefed regarding LA support staff attending for week two of testing.  A visit was arranged for colleagues from Rhondda Cynon Taf to attend schools in operation to learn about the set up and implementation of this initiative.

6.3. SECONDARY SCHOOL MASS TESTING – LOWER CYNON VALLEY

Due to the later start date of the lower Cynon Valley pilot, staff and pupils in this area were offered one test in the school environment and encouraged to take up community testing the following week.

Methods used: Rhondda Cynon Taf Education and Inclusion Services established a project planning group in November 2020. The resulting project plan33 identified each stage (planning; implementation; results

33 Lower Cynon Testing Pilot Project Plan (see appendices)

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and completion) with detailed milestones/actions for each responsible officer. A lessons learned capture log supported this plan34. An operational guidance document35 was produced which details the systems and processes and associated location, staffing and operational requirements to administer testing in an efficient, safe and timely manner.

During the period of 7th to 9th of December 2020, all children and staff in Mountain Ash Comprehensive School were offered the opportunity for a LFD test within the school.

Concerns identified/lessons learned: The lessons learned capture log, highlighted the following:

Planning  Earlier communication from WG regarding the confirmation and announcements of the testing would have been beneficial to enable sufficient planning time. Site set up  Pupil testing areas - booths were not effective as there was no line of sight to pupils to ensure tests were being completed correctly. Examination desks used. Screen with mirror attached for pupils' ease of use to undertake the test.  Contingency plans need to be put in place if no Wi-Fi is available or is disrupted; LA staff required connectivity to access pupil data.  Estimate quantities of PPE and cleaning materials required on site for duration of opening.  Ensure there is a clear re-order process. Have one person in charge of all PPE and supply deliveries (preferably council officer) to avoid duplication.  Estimate quantities of test kits, barcodes and NHS cards, required for the duration of testing period. Ensure that these supplies are delivered at least a week in advance of testing commencing (these were supplied to Rhondda Cynon Taf on the late afternoon on Friday and we began testing commenced on the Monday).  Ensure there is clear re-ordering process. Supply/logistics  Queue management - pupils queued in an area outside the hall and this time was used to complete a procedure briefing and to distribute the NHS cards and barcodes.  Ensure NHS barcodes are available at the outset to enable pupil identification through the ‘Sims’ system and for card pupil information to be prepopulated. Delays were experienced in this regard. Testing process  Ensure there is a procedure to contact, isolate and inform parents of positive pupils. Identify and make subsequent arrangements for the testing of close contacts.  The NHS Wales Information Service (NWIS) phone registration was inefficient. Registration and results were uploaded after all testing was complete. It took a team of 5 people a day to register and update results. An excel import into NWIS would be more efficient and accurate data would be provided. Workforce/training  Sufficient numbers of testing staff are required to ensure no delays. Also, staff contingency in the event of any staff absences.

34 Lower Cynon Testing Pilot Lessons Learned Capture Log (see appendices) 35 Operational Guidance Mass Testing Mountain Ash Comprehensive School (see appendices)

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 Rhondda Cynon Taf had to independently source relevant training (to undertake the tests and the correct use of PPE). Improved signposting would have been beneficial.  Training – A supply of test kits and PPE should be made available to undertake training prior to the testing taking place.

What went well?  Invaluable first-hand experience of observing testing in two schools in Merthyr Tydfil to inform local arrangements.  Train-the-Trainer approach was adopted and worked well, with thanks to Merthyr Tydfil County Borough Council colleagues.  Training took take place in the actual location where test procedure and pupil flow could be demonstrated.  Inclusion of the Local Health Board nursing and clinical support staff was considered to be hugely positive in terms of student influence, engagement and high quality instructional support; their presence and skilful intervention undoubtedly helped ensure that some of the more vulnerable students undertook their tests. There was only one invalid test throughout the testing.

6.4. RESOURCES

This section focuses on the workforce, logistical and financial resources required as part of the schools based testing.

6.4.1 WORKFORCE RESOURCES

It should be noted that the Merthyr Tydfil model had a higher population coverage and as a consequence there were economies of scale.

Work has been undertaken by finance colleagues to identify the expenditure that represents ‘additionality’, noting that wherever possible, existing resources were deployed to deliver the pilots. Table 3, shows the workforce deployed to complete the testing in both Merthyr Tydfil and the lower Cynon Valley.

Table 3: Schools workforce resources*

Merthyr Tydfil Lower Cynon Valley TOTALS

Full Time Full Time Full Time Actual no. Actual no. Equivalent Equivalent Actual no. of Equivalent of staff of staff (FTE) Staff (FTE) Staff staff utilised (FTE) Staff utilised utilised Numbers Numbers Numbers

Schools 76 20.74 41.0 16.7 117.0 37.4

*This table was presented in the schools section, but is repeated here for ease of reference

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Note: Merthyr Tydfil includes 4 Comprehensive Schools, 1 Special School and 1 Pupil Referral Unit. The lower Cynon Valley pilot included 1 Comprehensive School.

6.4.2. LOGISTICAL RESOURCES

Procurement teams sourced the following resources to enable the testing:  Testing Equipment – testing kits, clinical waste bags, barcodes, NHS cards, phones.  PPE – gloves, masks, visors and aprons.  Cleaning – cleaning products included virucidal wipes, spray, hand sanitiser, tissues. Onsite cleaners were redeployed to support the cleaning down of testing stations between pupils.  Equipment – exam desks, sneeze screens, mirrors, bins, vomit receptacles, yellow lockable clinical waste bin.  Signage – floor markings (directional arrows) 2 metre distance signs, testing guidance for pupils.

6.4.3. FINANCIAL RESOURCES

Table 4, provides a summary of the costs associated with the delivery of testing within the schools (Merthyr Tydfil and the lower Cynon Valley).

Table 4: Summary of costs associated with schools tested**

RCT - Lower Cynon Merthyr Tydfil Valley MASS POPULATION TESTING - SCHOOLS Total Costs - Schools Testing (Staffing Costs) £64,458 £21,843

Lateral Flow Tests (LFT) Number of LFTs Undertaken 3,588 476

Cost per LFT - Schools (i.e. in relation to the costs incurred by LAs) - excludes cost of the test £17.96 £45.89 equipment (assumed funded by UK Govt)

**This table was presented in the schools section, but is repeated here for ease of reference

It can be seen that the cost per test varies considerably between the two Local Authority areas. Table 5, shows a comparison of school and community testing with average costs.

Table 5: Cost per tests in community and schools

Community School Merthyr Tydfil £14.73 £17.96 Lower Cynon £32.49 £45.89 Valley Average cost* £20.01 £21.24 *Calculated as total cost of tests in all community venues or schools divided by total number of tests in each setting.

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The average cost of delivery in the community and schools is very similar. The variation in cost between Merthyr Tydfil and the lower Cynon Valley arises from the fact that although total costs for both pilot areas was similar (reflecting broadly similar project planning, delivery and physical infrastructure arrangements), there was a significant difference in the targeted population and the resulting number of tests undertaken - 35,001 and 3,588 respectively for community and schools in Merthyr Tydfil and 14,798 and 476 in the lower Cynon Valley. The difference in the total number of tests for each area has been a key factor in driving the ‘cost per test’ unit costs calculated.

6.5. TESTING AND ANALYSIS OF UPTAKE OUTCOMES

The data for the school’s uptake and positivity was not able to be analysed separately from the Whole Area Testing pilot analysis. However, inferences can be drawn from the analysis, as follows.

6.5.1. UPTAKE Figure 10: Lateral Flow Device tests in Merthyr Tydfil, by age and gender, 21st November to 18th December 2020 (all tests including repeats)

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Figure 11: Number of LFD tests in the lower Cynon Valley, by Age and Gender, 5th December to 22nd December 2020

Figures 10 and 11 (above), demonstrate that the schools pilot contributed greatly to the inclusion on the population age group 11-19 years with 4,064 LFD tests undertaken in schools. In addition there was a reasonable split in gender uptake. The attendance at schools for the testing period is shown in Tables 6 and 7 (below).

In Merthyr Tydfil it can be seen that attendance reduced 68.7% in the week beginning 30th November, when testing commenced in the schools, and further to 50.1 % in the week beginning the 7th December. In the lower Cynon Valley the attendance was 68.8% for the week beginning 7th December, when testing commenced.

Given the lower levels of attendance and the significant contribution of school-based testing, this demonstrates the importance of the school setting in encouraging uptake.

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Table 6: Merthyr Tydfil – Weekly attendance rates (all settings)

Week Commencing Attendance Ave (%) 01/09/2020 07/09/2020 14/09/2020 87.4 21/09/2020 68.1 28/09/2020 59.0 05/10/2020 66.9 12/10/2020 69.8 19/10/2020 61.0 26/10/2020 Half term 35.7 02/11/2020 Year 9,10,11 online learning only 09/11/2020 82.2 16/11/2020 76.1 23/11/2020 73.5 30/11/2020 68.7 07/12/2020 50.1 14/12/2020 Online Learning 21/12/2020 Schools Closed

Table 7: Lower Cynon Valley - Weekly attendance rates (Mountain Ash Comprehensive School)

Week Commencing Attendance Ave (%) 01/09/2020 28.7 07/09/2020 78.5 14/09/2020 73.9 21/09/2020 73.4 28/09/2020 81.0 05/10/2020 86.1 12/10/2020 86.0 19/10/2020 78.3 26/10/2020 No attendance 02/11/2020 No attendance 09/11/2020 84.5 16/11/2020 85.2 23/11/2020 83.6 30/11/2020 80.7 07/12/2020 68.8 14/12/2020 Online Learning 21/12/2020 Schools Closed

One school observed that non consents were high amongst pupils with English as an additional language (EAL), possibly linked to zero hours work contracts and implications for those families.

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Some pupils who did not consent to testing in week 1, consented in week 2, indicating they became more comfortable with it after others had completed the tests.

Some pupils were taken to the community mass testing sites operating within the Merthyr Tydfil and the lower Cynon Valley areas. These may have also included children who resided in the pilot areas, but who are educated outside of the pilot areas (e.g. children attending Welsh medium and faith schools).

6.5.2. POSITIVITY RATE BY AGE GROUP

Figures 12 and 13, show the rates of positivity in different age groups in Merthyr Tydfil and the lower Cynon Valley.

Figure 12: LFD positivity rates by age group, Merthyr Tydfil, 21st November to 18th December 2020

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Figure 13: LFD positivity rates by age group, lower Cynon Valley, 5th - 22nd December 2020

Of the 4,064 LFD tests undertaken in schools, there were 15 positive test results. This is a positivity rate of 0.37% in school pupils. This compares with a population positivity rate in Merthyr Tydfil of 2.3% and the lower Cynon Valley of 2.6% for the Whole Area Testing pilot. Whilst not all school staff and children were tested and some may have gone to community testing facilities, it is clear that the positivity rate is much lower in the school environment than in the community. This provides strong support to the theory that school-based transmission is very limited, as observed in the Review of transmission of COVID-19 associated with schools in Cwm Taf Morgannwg.

When all testing is analysed by age group in both areas, it can be seen that the positivity rate of the 11-19 age group, that includes school pupils in this pilot, is much higher, indicating that isolation from the school environment is effective. This higher positivity rate in the general population of 11-19 year age group could also be reflective of higher rates of positivity and infection in older children and young adults, as post 16 education is provided by the college in Merthyr Tydfil, whose students’ also participated in community testing.

6.6. COMPARISONS – LEARNING FROM OTHER AREAS36

Liverpool mass testing pilot:37

In Liverpool, half of secondary school pupils took up testing, impacted by negative media from outside Liverpool. Following a briefing on Thursday 8th November for secondary school head teachers to prepare for testing at schools, an opt-in consent process was agreed. However, one school (not at the briefing) misunderstood their school would begin testing on the following Monday and sent an opt-out letter to parents on the Friday. Although this was recalled and replaced with an opt-in letter

36 Liverpool for comparisons 37 Reference Liverpool “Interim Report on Liverpool Covid-19 Community Testing Pilot”

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on Sunday, it fuelled negative discussion on social media, which damaged uptake of testing at schools. Rates of consent varied considerably by school. An average of 52.6% of pupils at participating secondary schools (31 out of 33) were tested. A total of 32,411 tests (84% pupils; 16% staff) were done at schools. Although community testing in Liverpool had a much lower participation rate, this data also supports the importance of school-based testing in the uptake rates for this age group as shown in Figure 14.

Figure 14: Proportion of Liverpool City population by age group taking up LFD tests

6.7. SYSTEMS AND PROCESS WORKING

Merthyr Tydfil - The huge amount of time and commitment was required by all involved and cannot be under-estimated. This is a daily (including weekends) intense process of ‘learning from scratch’. A timeline included in the Merthyr Tydfil Secondary School Mass COVID-19 Testing Report2 (pages 6- 9) details the intensity of activity.

There was a real benefit of daily meetings to plan, but the volume of pupils within each setting will greatly affect this planning.

It was considered to be very useful to have Environmental Health Officers (EHOs) present during testing and the advice they offered relating to infection control and cleaning procedures was valued. The EHOs praised local processes.

The vast majority of parents were very supportive and grateful.

Lower Cynon Valley - There is a need to ensure that an appropriate amount of time is allocated to plan robust processes and procedures. Schools will need to commit the appropriate staff, time and resources to enable the development and implementation of a robust project plan with relevant

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timescales. Rhondda Cynon Taf established a corporate project team of senior officers to deliver both the community and school-based testing, which met on a daily basis to develop the project plan and to manage any exceptions raised. This team comprised of officers from Public Health, Education, Streetcare & Waste Management, School Transport, Communication Team, Community Services, ICT, Estates, Finance and Procurement. The school Governing Body was supportive, and the Chair received a daily progress report from a senior education officer.

The vast majority of parents and carers were supportive of the process as it ensured continuity of their children’s learning. Pupil behaviour was exemplary, and they were keen to take part in the process.

CONCLUSIONS: In concluding this section of the report, it is important to reflect back on the aims and objectives of the Whole Area Testing pilot, in which the schools pilot was embedded. The aims were:

1. To test whether or not large-scale testing can yield a significant and sustained reduction in community transmission. 2. To make testing accessible to an agreed area(s) entire population and incentivise uptake. 3. To identify index cases and prevent further transmission through contact-tracing and other measures. 4. To protect those at highest risk. 5. To empower the local community to arrest and reduce the community spread to as low as reasonably possible in order to save lives and save livelihoods and businesses. 6. To identify those who are needlessly self-isolating and empower them to return to usual activities. 7. To assess the impact of testing on behaviour of participant.

In respect of aim 1, this will be assessed as part of the evaluation of the Whole Area Testing pilot, currently ongoing. It is clear that the schools pilot demonstrated that this was a significant element of aim 2, to make testing accessible to the area’s whole population and uptake was incentivised through clear communication with parents and carers. In addition, it contributed to aim 3, by identifying 15 asymptomatic cases and isolating them and their contacts to break chains of transmission. Isolating cases and contacts contribute to aim 5, protecting those at highest risk. The uptake rates in schools indicate that school communities were empowered and participated. The pilot did not specifically target those pupils who were self-isolating, although they may have attended community testing venues. There were no behavioural insights work in the school pilot, to assess aim 7 to look at the impact of testing on participant behaviour.

The objectives of the Whole Area Testing pilot were to: 1. Develop a blueprint for whole town, city, borough or regional testing. 2. Better understand prevalence via asymptomatic surveillance. 3. Develop an intelligence picture and use asymptomatic testing to limit an agreed area’s acceleration through enhanced restrictions escalation. 4. Deploy new technologies in an agile and scalable way.

The schools pilot achieved objective 1, providing standard operating procedures to form a blueprint for future testing in this setting. It clearly achieved objective 2, in understanding the much lower positivity rate in schools than in the wider community, adding to other observational work. The schools pilot contributed to objective 3, by providing useful intelligence to inform further targeting of

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community testing. The pilot also contributed to objective 4, demonstrating that the new technology of LFD testing could be quickly applied to school environments.

The schools pilot was a success in achieving and contributing to the aims and objectives of the Whole Area Testing pilot and demonstrated that it is feasible and possible to undertake whole school testing with LFDs. This was achieved with the good will and determination of Local Education Authority, school and other supporting staff with the aim of ensuring it was safe for pupils to continue their education in the school environment during the Pandemic.

The low proportion of positive asymptomatic cases indicates that the control measures through the Test, Trace and Protect system, together with the control measures in place in secondary schools are effective. As with the Liverpool schools pilot, this pilot indicated the importance of school based testing in encouraging uptake of testing. In addition the process of testing generated confidence in this setting to undertake testing and isolate asymptomatic staff and pupils.

The lessons learned during the schools pilot will inform any extension to the wider school communities.

The rationale for undertaking mass testing is ultimately about children and getting them back into an educational routine. Every person who is infectious but asymptomatic is potentially a “super spreader”. It is important that asymptomatic carriage is identified early to break routes of transmission.

One size does not and cannot fit all in schools, and Head Teachers and Senior Leadership Teams have to have ownership of how the process is undertaken, and the delivery model in their school, so it works for that school community.

Many schools had to suspend their normal teaching and use of facilities such as sports and dining halls whilst undertaking testing, and this is clearly impractical if mass testing was to be established in the longer term. However, on balance, the disruption caused by undertaking LFD testing is clearly less significant than self-isolating for a 10 day period.

It is evident how incredibly and rightly proud the school community are of their achievements.

RECOMMENDATIONS: The pilot in schools demonstrated that whole school testing was possible and successful. The following recommendations are made to assist further roll out in Wales:

1. Whole school testing requires considerable resources to facilitate the process. Sufficient time to plan the introduction of whole school testing should be allowed to effectively introduce the testing. 2. Co-ordination from the Local Education Authority is essential to facilitate good communication, the logistics and equipment needed, and to quickly respond to any issues arising.

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3. The School Leadership Team should have the flexibility to allow each school to determine the most effective way to deliver the programme in their environment. If all teams are trained, they can take ownership of the programme using generic operational guidance in support. 4. Effective communication with staff, pupils and parents or carers is essential to ensure trust in the programme and high uptake. 5. Messaging to schools should be streamlined, as multiple sources can be confusing. Clear guidance is needed from Welsh Government, allowing scope for bespoke operational arrangements that can be tailored to reflect the local needs of each school community. This should include: a generic pack for schools, with practical examples such as animated videos showing the test in process, etc. Training materials already in circulation within the UK (e.g. Universities) should be assessed by the Welsh Government, and if suitable adapted for use within schools in Wales, e.g. Welsh language. 6. Effective, accessible IT systems should be available to support the testing process and equipment such as bar code readers should be provided. 7. Clarity on flow of data for General Data Protection Regulation (GDPR) purposes would be beneficial. 8. Whole school testing is very disruptive to teaching and normal delivery of the curriculum. If introduced, it would be helpful to limit it to the start of the school e.g. start of term or immediately following lockdown when schools are closed. 9. The LFD test is quick and effective in identifying asymptomatic cases. The use of this test for contacts of cases has great potential to limit the number of children self-isolating and missing school. If such contacts opt out of testing, self-isolation for 10 days after the last contact must be maintained, as well as for any days that the test is not available e.g. weekends and holidays. 10. In using a more selected testing process e.g. for staff and pupil contacts of cases, routinely in schools, it should be noted that there are some limiting practical factors in this approach. In particular, the testing would need to commence at the start of the school day, pupils undergoing the test would need to be isolated until the results are known. This has the potential to create a bottleneck at the start of the school day. In addition there is limited space to test large numbers of pupils, without disrupting other school activities e.g. dining halls. This could only be undertaken for small numbers of contacts and not whole year groups. Guidance may need to be amended to provide greater clarity to identify true contacts rather than class, year group or travel bubbles. Contingency arrangements would need to be put in place to safely isolate any positive cases until parents could collect them or safe transport is arranged. This will cause particular problems for schools with a large catchment area reliant on school transport, if parents or carers cannot leave work at short notice or do not have access to a car. 11. Selective use of LFDs could be extended to all staff to maintain numbers at work, including agency and peripatetic staff, interview candidates and contractors entering the school environment.

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7. RESOURCES

This section provides an overview of the resources deployed in the preparation and delivery of the Whole Area Testing pilot. This includes workforce, logistical (such as sites and equipment) and financial resources deployed.

7.1. WORKFORCE RESOURCES

The section above, on the governance, planning and implementation of the pilot, provides an overview of the type of workforce resource and time committed that was required for the strategic leadership, planning and project management of the over-arching pilot and two local geographical area elements of the pilot. This element of the workforce has also been included in the costings below. In terms of the actual front line delivery of the testing service, identifying, securing and training the workforce was one of the most challenging aspects of the pilot.

In the Merthyr Tydfil area, 155 Military personnel were secured via Military Aid to Civilian Authorities (MACA) to assist in the roll-out of the pilot across the County Borough, but this was after the launch of the main hub site at Merthyr Tydfil Leisure Centre, for which the Local Authority had to source staff themselves. The additional Military personnel were only involved on a fixed term basis and therefore a workforce transition plan was required so that Military personnel could exit and Local Authority staff take their place where required.

In the lower Cynon Valley area the Local Authority provided all the required staff from the off-set, moving staff from non-essential roles at the time into the Whole Area Testing pilot as a priority.

A workforce was developed, using the blue print from the Standard Operating Procedure and experience shared from the Liverpool pilot and the Military, to outline an organisational structure for the testing sites for the pilot.

The job roles include the following:

 Area Testing Site (ATS) Site Manager - responsible for the overall running of the ATS.  Bay Co-ordinator - responsible for the routine management and co-ordination of the ATS on behalf of the Site Manager; provides assistance and guidance to other staff.  Processing Operative - conducts the elements of the LFD testing process.  Cleaning Staff - cleans in accordance with agreed instructions.  Test Assistant - guides participants through their involvement in the testing process, is responsible for guiding participants’ movements within the ATS and for instructing participants on how to conduct a swab.  Registration Assistant - aids participants through the registration process as required by those without access to personal IT (smart phone) or that lack the technical ability to register without assistance. More participants required assistance that was originally anticipated, this will be exacerbated by demographic factors.  Results Recorder - checks the results of completed tests and records them on the relevant IT system. A written template designed by the operative may be used to track the number of tests and ensure all are checked and subsequently released on schedule. Each test may have a serial number next to it, to track the number of tests per day.

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 Supplies Co-ordinator - the storeman for the ATS manages and co-ordinates: the in loading and out loading of stores, and tracks usage of stores on behalf of the ATS Comd (Manager). This can be a secondary duty depending on workforce requirements.  Queue Co-ordinator - the queue co-ordinators act as ‘Greeters’. Assess the participant’s requirements, manage expectations of queue times, aids the registration assistants and act as the liaison between participants in the queue and the ATS Site Manager. May ask if there are any symptoms and assess the participants’ technical ability. If the participant is capable then they can be provided with a card and bar code to register with. If the participant struggles, they can be issued with a card only and asked to make themselves known to a registration assistant. It’s recommended to have someone prepared to manage complex situations.  Receptionist - responsible for checking registration and administration of participants. The receptionist can ask the individual to stick one of the bar codes on the card where indicated and issue a swab, then direct them to a testing assistant and tell the participant that the instructions are in the pods. They should not provide a long brief as this causes backlogs.  Runners - some ATS Site Managers have found that the use of runners to transport swabs increases the efficiency of the ATS. Site Managers must ensure that runners are complying with the PPE requirements of the job roles that they are assisting. For example by changing gloves every swab if taking them to the processing operative.

Taken from the local Standard Operating Instructions, workforce guidance indicated the following workforce ratios as a guide, as shown in Table 8.

Table 8: Recommended workforce ratios

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An analysis of the workforce resources deployed for the Whole Area Testing pilot in Merthyr Tydfil and the lower Cynon Valley is set out in Appendix38, and a summary in Table 9.

Table 9: Summary of workforce resources

With regard to Full Time Equivalent staff numbers for each workforce area (excluding Military personnel), this has been based on the testing sites and duration of the pilots as set out in 5.2.1 (with the approach being to calculate the total number of hours worked, divided by the full duration of each respective pilot (to calculate a daily number of hours over the pilot period) and then divided by a standard number of full time daily hours i.e. 7 hours 30 minutes (Health) or 7 hours 24 minutes (Local Authority)). The ‘Actual no. of staff utilised’ total is significantly higher than the total ‘Full Time Equivalent (FTE) Staff Numbers’ due to officers working differing hours on different days (including rotas), for example, officers undertaking cleaning duties typically worked less than full time equivalent hours each day – this translated into 12.5 FTEs but 51 people were needed to undertake these duties (reflecting cleaning duties being required at multiple sites on the same days).

38 Mass population testing in Merthyr Tydfil and lower Cynon Valley - summary of costs (see appendices)

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In addition to the above, testing was undertaken in specific comprehensive schools and residents were also provided with the option of undertaking a home test. The workforce resources for each are set out in Table 10, below:

Table 10: Schools workforce resources

Merthyr Tydfil Lower Cynon Valley TOTALS

Full Time Full Time Full Time Actual no. Actual no. Equivalent Equivalent Actual no. of Equivalent of staff of staff (FTE) Staff (FTE) Staff staff utilised (FTE) Staff utilised utilised Numbers Numbers Numbers

Schools 76 20.74 41.0 16.7 117.0 37.4

Note: Merthyr Tydfil includes 4 Comprehensive Schools, 1 Special School and 1 Pupil Referral Unit. The lower Cynon Valley pilot included 1 Comprehensive School.

Home testing – the workforce resources (Table 11) relate to the lower Cynon Valley pilot only, where officers made telephone contact with residents on the shielded patient list to inform them of the option of a home test and, at the same time, aimed to help alleviated residents’ anxiety. The resources required to do this were considerable and a judgement would be needed as to the value of this additional engagement.

Table 11: Home testing resources for the lower Cynon Valley

Lower Cynon Valley

Full Time Actual no. Equivalent of staff (FTE) Staff utilised Numbers

Total - Shielding Lower Cynon - 17 officers deployed and Patient List calling (to 17.0 17.0 worked full time on the project over a 9 make residents aware day period of hometesting option)

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A key point to note in terms of workforce resources is the availability of sufficient capacity within each organisation to enable the planning and delivery of whole area population testing. For the Merthyr Tydfil and the lower Cynon Valley pilots, the pool of resources were deployed through repurposing existing staff members, this being achieved through a slowdown of some core activities, utilising spare capacity within some frontline services that were already affected by lockdown restrictions (e.g. Abercynon Leisure Centre being closed to the public) and engaging additional agency workers to support the delivery of the pilots.

Workforce lessons learned: The following provides a summary of some of the main lessons learned from a workforce perspective during the pilot, which may be of assistance to others considering the adoption of a similar approach:

Do not underestimate the workforce planning and amount of staff required, including building in contingency arrangements. If Military personnel are being used to help the service get up and running, there is a need to have transfer arrangements in place for when the Military remove their workforce, if some services are to remain in situ. Ensure enough tests, IT, PPE, barcodes and other kit is available to support training purposes prior to opening. Allocate staff numbers and roles prior to opening of site. For any satellite sites, ensure staff are able to experience or at least witness how the centre(s) work that are already open, prior to deployment). In this pilot, Merthyr Tydfil Leisure Centre was utilised as the training centre for new staff before redeployment. Importantly, ensure that the personal protective equipment policy and procedures are confirmed with all staff. Ensure there is clear direction on the viability of staff numbers and potential skills in areas such as the following: o Front of house – customer service skills o Queue Manager – customer service skills o Testing Assistant – customer service skills o Analyst – dexterity, repetitive, processing o Additional support roles : morning stock take, collection of daily statistics. Provide enough information from an engagement perspective so that potential staff understand risks and testing protocols. Adequate numbers of staff are required to ensure there is a balance between registrations and testing; this may well need to be flexed with experience, as required. Rotas need to be flexible and planned for the duration of opening (for the shorter opening sites) in advance. Staff coming through the system need to complete new starter forms in advance.

Operating procedure for the testing room - staff must include end of day clean and disposal of all waste – generate basic duty lists for each role. Allocation of duties to staff based on skillset (e.g. stock control).

Staff should be trained in all aspects to allow them to move from job to job, this helps with breaks and variety. Do not underestimate the time it takes to build a rota for site operation.

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In the pilot experience, in terms of staff safety, out of 14,000 tests, only 1 staff member tested positive. This type of information needs to be share with staff involved so they have clear facts.

NHS On-line Training – access details provided by the Military. Information was sent out to each employee and reinforced in face to face training although there was no ability of ensuring completion. Pay rates need to be considered for different roles and there was some feedback about the ability to make roles more interchangeable. Good monitoring arrangements were required when authorising timesheets if staff did move in between roles throughout a shift. Staff aged under 18 – when queried with Welsh Government about whether staff aged under 18 could undertake the testing role, there was no specific guidance about age in the SOP as it focused more on having appropriately trained individuals. It was suggested that we should gain agreement from Public Health Wales. Due to the time constraints at the time we ensured that those aged under 18 were employed as Processing Assistant/Receptionist and not Testing Assistants.

Shift Pattern – number of staff – initially the numbers were based on the assumption that staff would undertake the long shifts (11 hours). If working on a standard 7.5 working day more staff would have been needed. The preference during the pilot was for staff to work longer shifts which would reduce cross overs and staff testing hours. Whilst the pilot testing centres were only open for a short period of time, this worked fine and there were some other shifts patterns in place. However should mass testing continue for longer periods, then consideration should be given adopting a specific rota/working pattern.

All staff involved in the pilot should be commended for their flexible and supportive approach in helping make the pilot work. A ‘train the trainer’ approach was adopted and this worked reasonably well. Face to Face Training – worked well with Train the Trainer approach. Positive feedback was received. Since the training, Managers have developed a video which will show staff what to expect at the Testing Centres – this will complement existing training and will be valuable particularly where training does not take place in a live testing setting. Set out clear job roles and work plans and use these in training, this definitely assisted and made sure all staff knew what they needed to do.

7.2. LOGISTICAL RESOURCES

In terms of delivering the testing service, there were a range of logistical resources that had to be deployed. As a reminder and in summary, details of the logistical resources deployed are set out below:

7.2.1. PHYSICAL INFRASTRUCTURE Merthyr Tydfil - Whole Area Testing was delivered between 21st November and the 18th December across 14 sites (noting that 1 site was open for the full duration (to 18th December) and the other sites for specifics days within this period).

The specific sites were: Merthyr Tydfil Leisure Centre, Aberfan Community Centre, Trelewis Community Centre, Bedlinog RFC, Dowlais Community Centre, The Willows Centre (Troedyrhiw), Clinic

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(Gurnos), Dowlais Engine House, Quakers Yard Community Centre, Cefn Community Centre, Pontsticill Memorial Hall, Alpha House (Heolgerrig)), Dowlais Rugby Club and St Matthias Church (Treharris).

Lower Cynon Valley Whole Area Testing was delivered between 5th and 20th December across 8 sites (noting that 1 site was open for the full duration and the other sites for specific days within this period).

The specific sites were: Abercynon Social Hall, Abercynon Sports Centre, Abercwmboi RFC, Cynon Valley Indoor Bowls (Mountain Ash), Cwmaman Hall, Fernhill and Glenboi Community Centre, The Feel Good Factory (Mountain Ash) and Penrhiwceiber Community Hall.

7.2.2. EQUIPMENT AND SUPPORT SERVICES

The equipment and support services required for the pilot included the following:

1. The UK Department of Health and Social Care (DHSC) provided the following to the Merthyr Tydfil pilot:  Sample collection kits and lateral flow antigen test devices  Digital enablement including barcodes and phones  Personal Protective Equipment (including gloves, aprons, masks, goggles/visors)

2. Merthyr Tydfil and Rhondda Cynon Taf County Borough Councils provided:  Physical infrastructure (including provision of booths and site security)  Clinical waste services  Communication and engagement services and materials  Equipment required for the set-up and day to day running of a test site, including: o Cleaning agents; o Tissues; o Signage and barriers; o Consumables (non-medical); o Catering; o Safety (including fire extinguishers, defibrillator); o Clinical waste (including bins, bags, containers); o General waste (including bins, bags, containers); o Miscellaneous (whiteboards, printers, tools etc.).

Lessons learned on the logistical elements of the pilot can be found in the section on logistics.

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7.3. FINANCIAL RESOURCES

This section sets out an overview of the gross costs (i.e. additional and opportunity costs) in preparing for and delivering the Whole Area Testing, and also provides cost per test information.

Summary of Gross Costs

A summary of the gross costs incurred to deliver LFD at mass population testing sites is set out in Table 12.

Table 12 – Total Gross Costs – Mass Population Testing Sites (non-schools)

RCT - Lower Cynon Merthyr Tydfil Valley MASS POPULATION TESTING SITES - NON- SCHOOLS Strategic Leadership (LA / Health / PHW) £19,641 £17,000 Project Management (LA) £23,607 £45,728 Project Planning (LA) £59,369 £64,858 Direct staffing (LA) £294,323 £222,996 Premises costs (via LA) £52,446 £87,882 Purchase of equipment & materials (LA) £41,068 £25,158 Support Service Costs (LA) £0 £7,010 Other costs (marketing, printing, etc) (LA) £25,234 £10,209 Total Gross Costs - Mass Population Testing Sites £515,688 £480,839 (Non-Schools) Note: Direct Staffing (Local Authority) for Merthyr Tydfil includes a notional cost for Local Authority staff to represent the staffing cost if Military support was not provided (with the actual cost of the deployment of Military personnel excluded from the analysis). In addition, work is currently on-going to identify the expenditure that represents ‘additional costs’ to the organisations, noting that wherever possible existing resources were deployed to deliver the pilots.

In terms of cost variations between pilots, the main areas included:

 Project Management – project management arrangements were put in place for each pilot. The number and range of officers (and their estimated time allocation) were specific to each pilot and covered the following key disciplines: designated project manager and designated deputy project manager; Environmental Health Officers; representatives from Adult Services and Children’s Services; Education officers (including Catering Services); Customer Care, ICT; Communications; Democratic Services; HR; and Finance;

 Direct Staffing (LA) – the key influencing factor being the size and scale differences of each pilot;

 Premises costs (via LA) – primarily due to the lower Cynon Valley pilot incurring site security costs (including overnight security) that were not incurred / to the same level for the Merthyr Tydfil pilot; and

 Purchase of equipment and materials – primarily driven by the extent that each organisation was able to utilise existing resources. Purchases included booths, containers, metal laboratory trays for testing, staff badges, staff flags and clicker counters.

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Cost Per Test Information

The costing and testing information has been brought together to calculate a cost per Lateral Flow Device / Positive Lateral Flow Device and Confirmatory PCR test, as set out in Tables 13 and 14.

Table 13: Gross costs per Lateral Flow Device Testing / Positive Lateral Flow Device Testing

RCT - Lower Cynon Merthyr Tydfil Valley Total Gross Costs - Mass Population Testing Sites £515,688 £480,839 (Non-Schools)

Lateral Flow Tests (LFT) Number of LFTs Undertaken (including colleges - 35,001 14,798 Merthyr Tydfil) Cost per LFT - Non-schools (i.e. in relation to the costs incurred by LAs / Health / PHW) - excludes £14.73 £32.49 cost of the test equipment (assumed funded by UK Govt)

Positive LFTs Number of Positive LFTs (including colleges - Merthyr 745 369 Tydfil) Cost per Positive LFT - non-schools (i.e. in relation to the costs incurred by LAs / Health / PHW) - £692.20 £1,303.09 excludes cost of the test equipment (assumed funded by UK Govt) The calculated Gross Cost Per LFD test for the lower Cynon Valley pilot (£32.49) is £17.76 higher than that calculated for the Merthyr Tydfil pilot (£14.73) - this is due to similar total costs for both pilot areas, reflecting broadly similar project planning, delivery and physical infrastructure arrangements, but a significant difference in the targeted population and the resulting number of tests undertaken i.e. 35,001 in Merthyr Tydfil and 14,798 in the lower Cynon Valley. The difference in the total number of tests for each area has been a key factor in driving the ‘cost per test’ unit costs calculated. This principle also follows through in the calculated unit costs for ‘Positive LFD tests’.

With specific regard to confirmatory PCR tests, it was required to have such tests done for every positive LFD test. To do this there was a team of 2 healthcare workers and 8 WAST staff on site every day for the full operational hours in each of the two main testing sites. A high number of people with positive LFD test chose not to stay for a confirmatory PCR test. The percentage of residents that did not take a follow up confirmatory PCR test after a positive LFD test was 48% in Merthyr Tydfil and 39% in the lower Cynon Valley. This meant that the teams were onsite to deliver an average of 12.5 confirmatory PCR tests per day per test site. The calculated gross cost per confirmatory PCR test is set out in Table 14.

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Table 14: Gross costs of confirmatory PCR test and cost per confirmatory PCR test

RCT - Lower Cynon Merthyr Tydfil Valley Confirmatory PCR Tests Health Service / Public Health Wales - Staffing £10,499 £6,461 Health Service / Public Health Wales - Non-Staffing Costs £11,445 £8,016 (including laboratory testing cost) Welsh Ambulance Service Trust £36,523 £22,475 Total costs of providing Confirmatory PCR testing £58,467 £36,952 Number of Confirmatory PCR Tests Undertaken 266 189

Cost per Confirmatory PCR Test - Non-schools £219.80 £195.52

The differences in the ‘total costs’ and ‘cost per confirmatory PCR test’ between each pilot were primarily due to:

 Confirmatory PCR testing provision being in place for 20 days for the Merthyr Tydfil pilot compared to 16 days for the lower Cynon Valley; and

 The Merthyr Tydfil pilot providing confirmatory PCR testing provision at two other community sites for 3 days, this provision not put in place for the lower Cynon Valley.

Schools (LFD tests)

Table 15 sets out a summary of gross costs and cost per LFD for school tests undertaken.

Table 15: Summary of gross costs and cost per tests in schools

RCT - Lower Cynon Merthyr Tydfil Valley MASS POPULATION TESTING - SCHOOLS Total Costs - Schools Testing (Staffing Costs) £64,458 £21,843

Lateral Flow Tests (LFT) Number of LFTs Undertaken 3,588 476

Cost per LFT - Schools (i.e. in relation to the costs incurred by LAs) - excludes cost of the test £17.96 £45.89 equipment (assumed funded by UK Govt)

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Home Testing Lateral Flow Device Tests

Table 16 sets out a summary of gross costs and cost per Lateral Flow Device for home tests undertaken.

Table 16: Summary of gross costs and cost per test for home tests

RCT - Lower Cynon Merthyr Tydfil Valley HOME-TESTING Number of LFTs Returned 1,096 797 Cost of Laboratory Test £38.00 £38.00 Total Cost per Home-Test (excludes outward and return postage £38.00 £38.00 - funded by UK Govt) Total Cost (excludes outward and return postage - funded by £41,648 £30,286 UK Govt)

Conclusions: It is evident that the staff and non-staff resources required to successfully deliver the pilot were extensive. Whilst the tests were provided by the UK Government, the planning, infrastructure and staff to deliver the tests in the community, schools and homes were considerable. The gross cost per LFD test varied considerably also, as summarised in Table 17.

Table 17: Gross cost per Lateral Flow Device test in community, schools and homes

Community Testing School Testing Home Testing * Merthyr Tydfil £14.73 £17.96 £38.00 Lower Cynon Valley £32.49 £45.89 £38.00 Average cost £20.01 £21.24 £38.00 * Home-testing - total cost of £38 relates to laboratory testing The average cost of delivery in the community and schools is very similar, but the cost of home tests is more than double. The key factor that influenced the varying average unit costs per LFD test undertaken in the Community, Schools and home testing was scale; the larger the targeted population and number of LFD tests undertaken, the lower the average unit cost, i.e., in Merthyr Tydfil the number of LFD tests undertaken in the community were 35,001, in schools 3,588 and home testing 1,096 and, in the lower Cynon Valley, 14,798, 476 and 797 respectively.

The variation in unit costs between the Merthyr Tydfil and the lower Cynon Valley pilots is due to similar total costs for both pilot areas, reflecting broadly similar project planning, delivery and physical infrastructure arrangements, and, consistent with the paragraph above, there was a significant difference in the targeted population and the resulting number of tests undertaken. This principle also follows through in the calculated unit costs for ‘Positive LFD tests’.

It is probable that as the testing is rolled out in the community, learning from experience, that the project management costs will be less. In addition if routine Confirmatory PCR testing is advised for positive cases with the LFD test, there would be no requirement for mobile PCR testing units to

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support the programme (and would eliminate the Health Service / Public Health Wales staffing costs and WAST costs as set out in Table 14).

Lastly, it is important to note that the cost analysis has been based on gross costs i.e. opportunity costs (where existing resources have been repurposed to deliver the pilots) plus additional costs incurred. Work is in the process of being finalised to determine the ‘additional costs’ to enable the appropriate reimbursement to the organisations involved and also assess affordability against the UK Government’s ‘£14 per test’ funding allocation.

Recommendations:

1. In order to accurately record resources used it is recommended that finance colleagues are engaged in the early planning and implementation including staff rotas. 2. Although it was possible to repurpose some existing staff roles, for example leisure staff while leisure centres were closed, additional staff were employed to support the pilot and this “additionality” needs funding commitment. 3. The value of additional calls to increase engagement for home testing should be considered as part of any further roll out, having regard to positivity rates in this population.

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8. ANALYSIS OF TESTING UPTAKE AND OUTCOMES

This is a key section of the report to examine the uptake of the testing in different population groups as well as the outcomes. This is important to assess the reach of testing and better understand transmission in the community. This will inform future action and control measures. This section also looks at the outcomes from a case control study undertaken during the pilot. In a case-control study individuals who have tested positive – cases - are identified and their past exposure to putative risk factors are compared with that of individuals who had negative test results - controls. This is compared using odds ratios, for example, the odds of being positive if you have a certain occupation compared with those who tested negative. Critically, this section also looks at the value of testing pilot in terms of cases and deaths prevented along with hospitalisation and intensive care use i.e. did the pilot make a difference?

8.1 UPTAKE OF TESTING

Merthyr Tydfil

Between 21st of November and 18th of December, 33,315 LFD tests were completed across 12 centres in Merthyr Tydfil. The target was to reach 75% of the total Merthyr Tydfil population (i.e. 45,000 people). This was a very ambitious target, particularly as those aged under 11 years were not targeted for the test. In 21,443 tests where a unique identifier (NHS number) was available, a total of 14,175 of those tests (66.1%) were in unique individuals. Applied to the 33,315 tests completed, this would translate to 22,021 individuals, representing an uptake rate 49%. This would include, mostly the resident population, but also some people working or learning in Merthyr Tydfil who may be resident outside the area, as shown in the heat map, Figure 15.

Figure 15: Heat map of uptake of testing over time in Merthyr Tydfil and the lower Cynon Valley

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As can be seen, the testing started in Merthyr Tydfil main testing station, attracting mostly people from the town and surrounding ‘heads of the valley’ villages. As more testing stations were opened further down the valley, attendance increased considerably. The final heat map shows the uptake increasing as the lower Cynon Valley stations are opened, stretching up to Mountain Ash. The dots outside the main geographical targeted areas, show uptake from others in surrounding areas, likely to be those working or studying in the target areas. However, it is clear that the population resident in the target areas accounted for the vast majority of uptake and opening locally accessible locations increased uptake and reach of the pilot.

Of those unique individuals, 9,280 (65.5%) had only one LFD test done during that period. Of the 763 positive tests, 396 (52%) went on to have a confirmatory PCR, the vast majority (384) doing so within 3 days of the positive LFD test.

Between 2nd December 2020 and 8th January 2021, 3,023 home LFD test kits were delivered to Merthyr Tydfil postcodes, of which 1,096 were returned, a return rate of 36%.

The vast majority of the tests (33,188, 99.6%) were in asymptomatic individuals.

Testing numbers varied by day with a range of 900 – 1,900 per day with typically lower numbers at the weekend compared to weekdays.

Figure 16 shows the distribution of tests at different sites in Merthyr Tydfil. It can be seen that the main hub consistently has the highest number of tests, as expected but the smaller spokes were important in extending reach and access to the wider population. This is particularly important as the valley geography and topography means that communities can be distinct and isolated from each other, with poor transport links and lower car ownership.

Figure 16: Number of tests conducted by day and testing site in Merthyr Tydfil

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Lower Cynon Valley

Between 5th of December and 22nd of December, 14,304 LFD tests were done across eight centres in the lower Cynon Valley. The target was to reach 75% of the total lower Cynon Valley population (i.e. 18,750 people). The lower Cynon Valley area is about 25,000 population covering Abercynon, Mountain Ash East, Mountain Ash West, Penrhiwceiber and Aberaman South. In 10,151 tests where a unique identifier (NHS number) was available, a total of 7,422 of those tests (73.1%) were in unique individuals. Applied to the 14,305 tests done, this would translate to 10,457 individuals, and representing an uptake rate of 56% of the eligible population.

Of those unique individuals, 5,702 (76.8%) had only one LFD test done during that period.

Of the 372 positive tests, 226 (61%) went on to have a confirmatory PCR, the vast majority (224) doing so within 3 days of the positive LFD test.

Between 11th December 2020 and 8th January 2021, 1,506 home LFD test kits were delivered to the lower Cynon Valley postcodes, of which 673 were returned (return rate of 45%).

The vast majority of the tests (14,248, 99.6%) were in asymptomatic individuals.

Testing numbers varied by day with a range of 600 – 1,300 per day with typically lower numbers at the weekend compared to weekdays.

Figure 17 shows the distribution of tests at different sites in the lower Cynon Valley. It can be seen that the main hub consistently has the highest number of tests, as expected but the smaller spokes were important in extending reach and access to the wider population. Again, this is particularly important as the valley geography and topography means that communities can be distinct and isolated from each other, with poor transport links and lower car ownership.

Figure 17: Number of tests conducted by day and testing site in the lower Cynon Valley

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8.1.2. AGE AND GENDER

In Merthyr Tydfil 18,518 tests (55.5%) were in women. The mean age of women in the tested population was 45.3 years (SD 19.6) and men were on average 46.0 years (SD 20.4). Figure 18 shows the age and gender of those presenting for LFD tests in Merthyr Tydfil.

Figure 18: LFD tests in Merthyr Tydfil, by Age and Gender, 21st Nov to 18th Dec 2020 (all tests, including repeats)

Similarly, in the lower Cynon Valley, 7,880 tests (55.1%) were in women. The mean age of women in the tested population was 44.4 years (SD 19.0) and men were on average 45.7 years (SD 20.0). Figure 19 shows the age and gender of those presenting for LFD tests in the lower Cynon Valley.

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Figure 19: Number of LFD tests in the lower Cynon Valley, by Age and Gender, 5th Dec to 22nd Dec 2020

8.1.3. DEPRIVATION

Uptake by deprivation of residence was monitored and analysed using the Welsh Index of Multiple Deprivation (WIMD) quintiles, where quintile one is the most deprived and quintile five the least. For both Merthyr Tydfil and the lower Cynon Valley, there was lower uptake in the most deprived groups, especially quintile one as can be seen in Figures 20 and 21. In the lower Cynon Valley there are no quintiles four or five demonstrating the greater deprivation in this area.

Figure 20: Testing Rate by Merthyr Tydfil WIMD quintile 21st November to 18th December 2020

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Figure 21: Testing Rate by lower Cynon Valley WIMD quintile 5th to 22nd December 2020

The socioeconomic gradient in uptake could reflect the possibility that the impact of isolating on household income might have been a significant barrier to participation for lower income groups.

8.1.4. OCCUPATION

The opportunity to disclose occupation was offered during testing. The uptake was highest in the public sector including teaching and education, health and social care, civil service or Local Authority employees, along with construction and manufacturing. This may reflect the fact that more people are employed in the public sector, by proportion in these areas that other areas of Wales and the encouragement of the manufacturing and construction industries, due to the impact on these essential sectors of workplace transmission. Payment during isolation in the public sector may also be a factor. Uptake was similar in Merthyr Tydfil and the lower Cynon Valley as shown in Figures 22 and 23. Of note also is that personal services such as hairdressers were the lowest represented in both areas. This may also be due to the impact of self-isolating on income.

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Figure 22: Occupation of tested population, Merthyr Tydfil

Figure 23: Occupation of tested population, lower Cynon Valley

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8.2. POSITIVITY

Positivity rates were analysed for the whole population and by different attributes such as geographical areas, gender, age or occupations, allowing a greater understanding of the reservoirs of infection and potential routes of transmission.

Positivity by area of testing station In Merthyr Tydfil between 21st of November and 18th of December, 33,315 LFD tests were completed across 12 centres. Of these, 763 were positive, representing a positivity rate of 2.3%. This ranged from 3.2% in Pontsticill to 0% in Trelewis testing stations, as shown in Figure 24 (below).

Figure 24: LFD Test Positivity Rate by Centre, Merthyr Tydfil, 21st November to 18th December 2020

In the lower Cynon Valley between 5th and 22nd of December, 14,304 LFD tests were completed across eight centres. The target was to reach 75% of the total lower Cynon Valley population (i.e. 18,750 people). Of these, 372 were positive, representing a positivity rate of 2.6%. This ranged from 3.7% in Abercwmboi to 0.7% in Mountain Ash as shown in Figure 25.

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Figure 25: LFD test Positivity Rate by Centre, lower Cynon Valley, 5th to 22nd Dec 2020

It is also interesting to compare the positivity rates found in the secondary schools pilot, as shown in section 6. The positivity rate for staff and pupils participating in the five secondary schools pilot shows that of the 4,064 LFD tests undertaken in schools, there were 15 positive test results. This is a positivity rate of 0.37% in school pupils and is significantly lower than that in the general community of 2.3% for Merthyr Tydfil and 2.6% for the lower Cynon Valley. The low proportion of positive asymptomatic cases indicates that the control measures through the Test, Trace and Protect system, together with the control measures in place in secondary schools are highly effective.

Positivity by gender

Although uptake of testing was higher in females than males in both areas, the positivity rate was higher in males in both areas, as shown in Table 18:

Table 18: LFD test positivity rate by Gender for Merthyr Tydfil, 21st November to 18th December and lower Cynon Valley, 5th to 22nd December 2020.

Area Positivity rate for females Positivity rate for males Merthyr Tydfil 2.0% 2.6% Lower Cynon Valley 2.3% 2.9%

This may indicate that males may have higher risk occupations or that they may be less compliant with control measures e.g. social distancing, hand washing and wearing face coverings.

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Positivity by age group

When looking at rates of positivity by age group, there are similarities for both areas. The highest rates of positivity are in those aged 20-29 years followed by 30 to 39 years, slightly higher at 4.2% in 20-29 year group in the lower Cynon Valley than Merthyr Tydfil at 3.2%. The later peak in those aged 80+ years in Merthyr that is not seen in the lower Cynon Valley. Figures 26 and 27 show the positivity by age band in Merthyr Tydfil and the lower Cynon Valley.

Figure 26: LFD test positivity rates by age group, Merthyr Tydfil, November 21st to December 18th 2020

Figure 27: LFD test positivity rates by age group, lower Cynon Valley, 5th to 22nd December 2020

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Positivity by deprivation

The positivity by quintile of deprivation has some variation between the two areas but the strongest feature is the highest rate of positivity in quintile 1, individuals living in the most deprived areas with 3.1% positivity rate in Merthyr Tydfil and 2.7% positivity rate in the lower Cynon Valley. This demonstrates that the poorest people in our communities bear an unfair burden of disease.

Figures 28 and 29 show the positivity rate by quintile of deprivation of residence for Merthyr Tydfil and the lower Cynon Valley.

Figure 28: LFD test positivity rate by quintile deprivation, Merthyr Tydfil, November 21st to December 18th 2020

Figure 29: LFD test positivity rate by deprivation, lower Cynon Valley, 5th to 22nd December 2020

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Positivity by Occupation

Positivity rates by occupation varied between both areas, as did uptake of testing. However, some interesting rates were seen with high positivity rates in Merthyr Tydfil seen in the sectors of transport 5.2%, hair and beauty 4%, hospitality 2.9% and manufacturing and construction 2.8%. In the lower Cynon Valley the highest rates were seen in manufacturing and construction 5.6%, hospitality 3.8%, health and social care 3.7%, retail 3.1% and arts and entertainment 2.9%. Both had high positivity rates in people who did not disclose their occupations 3.2% in Merthyr Tydfil and 5.5% in the lower Cynon Valley. These results confirm that the highest risk occupation are those where people have to go into work and therefore come into contact with a range of people, increasing the risk of transmission. Figures 30 and 31 show the positivity rate by occupation for each area.

Figure 30: LFD test Positivity Rates by Occupation, Merthyr Tydfil, November 21st to December 18th 2020

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Figure 31: LFD Test Positivity Rates by Occupation, lower Cynon Valley, 5th to 22nd December 2020

8.3. LATERAL FLOW DEVICE TESTS

The performance of the LFD tests has been assess during their rapid development. Public Health England, Porton Down and Oxford University confirmed that the Innova LFD test, used in this pilot, is good, has low failure rates, high specificity and high viral antigen detection39. The purpose of this study is set out in the aims and objectives and does not include the assessment of the test performance, but the ability to scale up use in the community.

Table 19 considers the advantages and limitations of the LFD test compared to the PCR test as outlined in two recent articles in the British Medical Journal40 and the Lancet41.

39 Preliminary report from the joint PHE Porton Down & University of Oxford SARS-CoV-2 LFD test development and validation cell 8 November 2020. https://www.ox.ac.uk/sites/files/oxford/media_wysiwyg/UK%20evaluation_PHE%20Porton%20Down%20%20 University%20of%20Oxford_final.pdf 40 BMJ 2021;372:n208 http://dx.doi.org/10.1136/bmj.n208

41 https://doi.org/10.1016/S0140-6736(21)00425-6

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Table 19: Advantages and limitations of the LFD and PCR tests for COVID-19.

LFD PCR Advantages: Advantages: Quick results (up to 30 minutes). This enables Powerful clinical test for detecting COVID-19, prompt isolation and contact tracing. 100% sensitive and 96.9% specific. Detects infectious cases and less likely to detect Samples can be used for whole genome post-infectious people. sequencing which can identify new variants of concern and assist with outbreak investigation. Can detect asymptomatic and pre-symptomatic cases who would not present for PCR testing. Relatively cheap test as no laboratory is needed. Can be scaled up quickly. Limitations: Limitations: Subject to error in sampling, particularly self- Tests have to be booked in advance and results sampling (untrained) which can result in false take up typically 24 – 48 hours which delays negative results. contact tracing to break routes of transmission. Less sensitive than PCR tests having more false Can provide positive results by detecting negative results. fragments of virus up to 90 days after infection when individuals are no longer infectious. This can result in unnecessary isolation. The infectious period is a short window to Expensive test due to laboratory requirements. identify infectious cases, therefore repeat testing is required for maximum detection. Does not quantify the level of virus detected to Only accessible to symptomatic individuals and indicate the level of infectiousness. therefore does not identify asymptomatic or pre-symptomatic but infectious cases.

Ultimately, any test is a snapshot in time and should not give assurance outside of that moment. The main advantage of the LFD test is that is provides rapid results to inform isolation and contact tracing, thereby breaking routes of transmission very quickly. The PCR test takes days to report and may therefore not offer the same opportunity for rapid interruption of transmission.

Indeed, the fact that PCR could detect virus after the infectious period has led to well-reasoned conclusions that it is not the appropriate gold standard for evaluating a SARS-CoV-2 public health test as it incurs a net loss to the health, social, and economic wellbeing of communities through post- infectious individuals testing positive and needing to isolate for 10 days (Mina et al, 2021).

In conclusion, in the context of community testing to identify asymptomatic individuals who are infectious, the LFD test has the advantage that it is quick, accessible and can be deployed at scale, allowing the introduction of rapid control measures to disrupt the chain of transmission at the earliest opportunity, thus reducing prevalence.

Recommendations:

1. Additional support to low income households to isolate is imperative for greater uptake and compliance.

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2. Targeting testing of low uptake occupations with higher positivity rates, including tailored financial incentives should be considered to increase uptake in these groups that have the potential to transmit COVID-19 to larger client base.

8.4. ESTIMATED CASES, HOSPITALISATIONS AND DEATHS PREVENTED IN MERTHYR TYDFIL

We assessed the impact of the whole area testing pilot that took place in Merthyr Tydfil Local Authority between 21st November 2020 and 20th December 2020 by estimating the number of cases prevented using the reproduction number (Rt) in Merthyr Tydfil at the time and applying a series of assumptions on the natural history of the infection and the performance of the test, and then applying these estimates to a time-lagged regression model to estimate the number of hospitalisations, ICU admissions and deaths prevented. We also performed sensitivity analysis on some parameters that underlies some of the assumptions of the analysis and derived estimates from likely worst-case and best-case scenarios.

Method Assumptions

The analysis presented carry the following assumptions.

1. Infectability of asymptomatic cases are 58% of symptomatic cases42. 2. The number of infections created by an infectious person is determined by the Rt value on the day of their Lateral Flow positive test result. 3. An infectious person became infectious 5 days before the Lateral Flow positive test result and up to 9 days after. Only infections taking place after the Lateral Flow positive test are considered preventable. 4. The daily count of new infections arising from infectious persons is a fixed Log-normal distribution with a median of 5 days43. 5. All infected persons not exhibiting symptoms will not self-isolate, therefore will contribute to subsequent infections. 6. Infected persons exhibiting symptoms will self-isolate, but will also contribute to secondary transmission (each symptomatic case will contribute 0.2 secondary cases in contacts). 7. The proportion of positive cases that will develop symptoms remains constant (0.44). 8. All cases reported asymptomatic are truly asymptomatic. 9. All positive Lateral Flow tests with confirmatory PCR test are true positives. 10. Of the positive LF tests without confirmatory PCR test, a fixed proportion will be true positives (0.89)

42 Byambasuren, O., Cardona, M., Bell, K., Clark, J., McLaws, M.-L., & Glasziou, P. (2020). Estimating the extent of asymptomatic COVID-19 and its potential for community transmission: Systematic review and meta- analysis. Official Journal of the Association of Medical Microbiology and Infectious Disease Canada, 5(4), 223– 234. https://doi.org/10.3138/jammi-2020-0030 43 McAloon, C., Collins, Á., Hunt, K., Barber, A., Byrne, A. W., Butler, F., Casey, M., Griffin, J., Lane, E., McEvoy, D., Wall, P., Green, M., O’Grady, L., & More, S. J. (2020). Incubation period of COVID-19: A rapid systematic review and meta-analysis of observational research. BMJ Open, 10(8), e039652. https://doi.org/10.1136/bmjopen-2020-039652

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11. All infected persons are equality infectious irrespective of age, gender, demographic variables, etc.

1. Estimates of cases prevented All lateral flow tests (LFD) performed at the 14 participating testing centres in Merthyr Tydfil LA during the testing period were counted for each day. From this, the number of Lateral Flow test positives that were confirmed by PCR test were counted. From this number, the number of true positives were estimated. Firstly we identified all LFD positives with a confirmatory PCR test result (classified as true positives). Secondly, we estimated the number of true positives in those who did not have a confirmatory PCR test from the positive predictive value (PPV) of the Lateral Flow test, estimated to be 0.89.

A proportion of asymptomatic cases will go on to develop COVID-19 symptoms. The number expected to remain asymptomatic was estimated by scaling the number of true positives by the proportion of asymptomatic cases that did not reported having symptoms when interviewed coincidentally as part of a case-control study that took place during the testing pilot (estimated to be 0.56). Asymptomatic infections are assumed to not self-isolate and therefore will contribute fully to the next generation of infections. A small proportion of secondary infections (0.2) were assumed for symptomatic cases, resulting from infectious contact made prior to onset of symptoms or as a failure of self-isolation. The sum of these two count constitutes the initial set of cases identified though the testing pilot but not directly prevented (also referred to as 0th generation infections). The process for obtaining this count is visualised in the flowchart in Figure 32 (below).

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Figure 32: Flowchart of process for estimating number of cases detected by mass testing that would not otherwise be detected.

From the initial set of cases, the 1st generation infections that would have occurred from these cases is estimated by multiplying by the reproduction number (Rt - mean and 95% CI) for that day by the number true positive LFD cases (Figure 33). A scaling factor of 0.58 is also applied to take into account the relative reduction of infectability of asymptomatic cases compared to symptomatic cases 42. The

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daily reproduction number Rt was estimated using the “EpiEstim” R package44 based on actual PCR- tested case counts in Merthyr Tydfil LA area.

Figure 33: Estimated Rt in Merthyr Tydfil over the testing period

The number of subsequent (2nd and higher generation) infections were estimated by iteratively multiplying the estimated Rt by the estimated number of prevented infections from the previous day, each time scaling the number of cases from the previous generation by the proportions of asymptomatic and symptomatic-infectious cases, and scaling the asymptomatic portion by the relative infectability of asymptomatic cases, as done for the 0th generation.

The number of infections estimated prevented for a given day is the sum of the 1st generation and 2nd and higher generation infections. 0th generation infection are excluded as they occurred before the LF test and therefore cannot be considered prevented.

The number of infections estimated for a given day is then distributed over an infection window of 14 days, which has a log-normal distribution (휇=1.63, 휎=0.5), with a median of 5 days. The parameters for this distribution were taken from the meta-analysis of McAloon et al. (2020)43. For 1st generation infections (infections arising direct from the LF positive cases) the infectious period is assumed to be centred around the LF test date, to take into account the likely delay between the date of infection and the date of the LF test. Only the infectious period after the LF test date is considered as any new infections generated before the LF test would not have been prevented. For 2nd and higher generation infections, the whole infection window is considered and the start of the infection window is the date the infection is seeded. A flowchart depicting this process is shown in Figure 34.

44 Cori, A., Ferguson, N. M., Fraser, C., & Cauchemez, S. (2013). A new framework and software to estimate time-varying reproduction numbers during epidemics. American Journal of Epidemiology, 178(9), 1505–1512. https://doi.org/10.1093/aje/kwt133

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Figure 34: Flowchart of process for estimating number of cases prevented, and other healthcare outcomes. This process is followed iteratively for each day in the testing period.

The proportion of asymptomatic cases was obtained from case-control study undertaken at the same time as the mass testing, from 198 LF positive results, 87 (44%) reported symptoms when followed up.

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The proportion of symptomatic cases that contribute to new infections was estimated from contact tracing data (restricted to the period of the mass testing exercise and to the Merthyr Tydfil LA area). The contacts for all cases that reported symptoms were cross referenced to identify those that also have a PCR-confirmed positive test result. The proportion of those in contact with positive test results was 0.2.

2. Estimates of hospitalisations, ICU admissions and deaths prevented The estimated number of cases prevented were further used to predict three healthcare outcomes: hospitalisations, ICU admissions and deaths. A time-lagged log-linear regression model was built on case data in the Merthyr Tydfil LA. Separate models were built for each healthcare outcome with multiple lagged case counts treated as the predictor variables and the burden measure as the outcome measure. Hospitalisation data were restricted to those where a positive PCR test was obtained no later than 2 days after admission. This rules out likely nosocomial infections, as opposed to those that are community-acquired. All data were log transformed and smoothed with a LOESS filter (span = 0.2). Models are built from time-lagged case counts with delays of 12-50, 24-50 and 30-50 days for hospitalisations, ICU admissions and death, respectively. These lag ranges were determined to be optimal by testing multiple lag windows of 1-50 days and comparing the AIC/BIC values.

The estimated number of cases prevented computed in the previous section were then fed into the model to predict daily counts of hospitalisations, ICU admissions and deaths prevented.

3. Sensitivity analysis Some of the proportions underlying the assumptions of the analysis have a high degree of uncertainty. Three parameters of concern were highlighted for sensitivity analysis and produce worst-case and best-case scenarios for the number of cases prevented and associated healthcare outcomes (worst case being highest number of cases prevented). All these parameters depend on to categorisation of symptomatic and asymptomatic cases. There are nuances in the definitional boundary between symptomatic and asymptomatic infection across studies45, including separate categorisations of presymptomatic and paucisymptomatic cases which were not made in this analysis. These nuances make this set of parameters particularly challenging to quantify. The parameters of concern are:

1. The proportion of asymptomatic cases that become symptomatic (assumption 7). This value of 0.44 was obtained from the follow up case-control study undertaken at the same time as the mass testing. This estimate is chosen due to its highly specific to the geography and demography of the mass testing sample. However, this is quite a high estimate compared to other estimates in the literature. In the systematic review of Oran and Topol (2021) 46, about three quarters of asymptomatic positive cases, never go on to develop symptoms. We therefore test against a lower best-case estimate of 0.25.

2. The proportion of symptomatic cases who contribute to further transmission (assumption 6). This value of 0.2 was obtained from contact tracing data in the Merthyr Tydfil LA, cross referencing contacts and identifying which contacts originate from symptomatic positive cases. Again, this is the chosen estimate for the main analysis as it is highly specific to the geography and demography of the

45 Meyerowitz, E. A., Richterman, A., Bogoch, I. I., Low, N., & Cevik, M. (2020). Towards an accurate and systematic characterisation of persistently asymptomatic infection with SARS-CoV-2. The Lancet Infectious Diseases, 0(0). https://doi.org/10.1016/S1473-3099(20)30837-9 46 Oran, D. P., & Topol, E. J. (2021). The Proportion of SARS-CoV-2 Infections That Are Asymptomatic. Annals of Internal Medicine. https://doi.org/10.7326/m20-6976

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mass testing sample. However, incompleteness in contact reporting means this value is likely to be under-estimated. A cross-sectional survey in the UK by Smith et al. (2020) 47 indicate the proportion of symptomatic cases who fail to self-isolate is much higher (0.75). We therefore use this as a best- case alternative for this parameter.

3. The relative infectability of asymptomatic cases compared to symptomatic cases (assumption 1). The value of 0.58 was obtained from the meta-analysis of Byambasuren et al. (2020)42. However, this estimate has very large confidence intervals (0.34, 0.99, with the upper bound treating the two groups as virtually equal in infectability. We do not have robust way of estimating this parameter in the mass testing sample, so we use the central estimate from this meta-analysis as the main parameter and the bounds of the confidence interval from this meta-analysis as best-case and worst-case estimates.

Results 1. Estimates of cases prevented A total of 33,822 LF tests were performed in Merthyr Tydfil LA. 712 were positive by LFD, of which 680 were estimated to be true positives, of which 381 were estimated to not subsequently develop symptoms and contribute to secondary infections. In addition, an estimated 60 of those developing symptoms would contribute to secondary infections. Figure 35 shows the daily count of these numbers over the testing period.

Figure 35: Positive lateral flow test results from community testing pilot in Merthyr Tydfil, with estimates for true positives and proportion remaining asymptomatic. Note that missing data in the weekend of 11th to 13th December is due to temporary suspension of the mass testing on these dates.

Including 1st and higher generation infections, a total of, a total of 353 (306, 409) infections are estimated to have been prevented in the period from 21st November 2020 to 3rd January 2021. This represents 12.2% (10.6%, 14.1%) of the actual case count (2,900), an effective reduction of 10.9% from

47 Smith, L. E., Amlȏt, R., Lambert, H., Oliver, I., Robin, C., Yardley, L., & Rubin, G. J. (2020). Factors associated with adherence to self-isolation and lockdown measures in the UK: a cross-sectional survey. Public Health, 187, 41–52. https://doi.org/10.1016/j.puhe.2020.07.024

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the would-be case count without mass testing (3,253). This also represents a reduction in mean daily incidence rate of 13.6 (11.8, 15.8) cases per 100,000 per day (actual mean daily incidence rate was 112 cases per 100,000 per day). This is the sum of 165 (153, 179) estimated 1st generation infections and 188 (153, 230) estimated 2nd and higher generation infections (see Table 20).

Table 20: Estimated cases prevented

Description n upper CI lower CI Actual case count 2900

LF test performed during mass testing 48834

- of which were in the Merthyr Tydfil LA 33822

- of which were asymptomatic and tested positive 712

– of which had a confirmatory PCR test result 538

– of which had no confirmatory PCR test 174

— of which were estimated to be true positives from PPV 155

- of which are true positives (PCR-confirmed + estimated from PPV) 680

– of which were estimated to remain asymptomatic 381

– of which were estimated to become symptomatic 299

— of which were estimated to still contribute to infections 60

direct cases (0th generation infections) prevented 441

1st generation infections prevented 165 179 153 2nd and higher generation infections prevented 188 230 153 Total estimated number of prevented cases 353 409 306

Figure 36 shows the cases counts in Merthyr Tydfil with and without those estimated prevented by the mass testing, over the course of the mass testing and the following 14 days.

Figure 36: Cases counts with and without estimated prevented by mass testing

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2. Estimates of hospitalisation, ICU admissions and deaths prevented The model estimates, from the cases prevented during the mass testing, a total of 24 (16, 36) hospitalisations, 5 (3, 6) ICU admissions and 14 (11, 19) deaths were prevented in the period between 21st November 2020 and 10th February 2021. These represent reductions of 6.65%, 11.4% and 8.31% of the actual hospitalisation, ICU admissions and deaths, respectively. The estimated time course of these three outcomes are shown in Figure 37.

Figure 37: Estimates of hospitalisations, ICU admissions and deaths prevented from cases prevented by mass testing

3. Sensitivity analysis Results of sensitivity analysis are shown in Table 21. The first two parameters tested (proportion of asymptomatic cases that become symptomatic and proportion of symptomatic cases who contribute to further transmission) produced small relative sensitivity values (magnitude below 1). The number of cases prevented when adjusting these values to less conservative estimates are 415 and 629, respectively (representing increases of 18% and 78% of the original estimate). However, sensitivity to the relative infectability of asymptomatic cases was very large (greater than 2). The number of estimated cases prevented in the less conservative scenario is 1041 (an increase of 195%). The model is therefore particularly sensitive to this parameter and so uncertainly in its estimation should be carefully considered when evaluating estimates produced by this model.

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Table 21: Results of sensitivity analysis

Absolute Relative Absolute Relative Parameter Original New parameter Parameter New output output Absolute Relative changed parameter parameter change change output change change sensitivity sensitivity Proportion of 0.439 0.250 -0.189 -0.431 415 62 0.176 -327 -0.407 symptomatic cases who become symptomatic Proportion of 0.201 0.751 0.550 2.735 629 276 0.782 502 0.286 symptomatic cases who contribute to further transmission Relative 0.580 0.990 0.410 0.707 1041 688 1.949 1678 2.757 infectability of asymptomatic cases, compared to symptomatic cases

Table 22 shows the estimated cases prevented for different scenarios tests with alternative worst- case and best-case parametrisations, the worst-case scenario being 157 (139, 176) cases prevented, which is 44% of the original estimate and 5% of the actual case count. The best-case scenario is 2252 (1712, 2986) cases prevented, which is 638% of the original estimate and 77% of the actual case count. Corresponding healthcare burdens prevented for the best-case scenario are 65 (48, 91) hospitalisations, 9 (7, 12) ICU admissions and 32 (25, 41) deaths. These represent reductions of 18.2%, 22.5% and 18.4% of the actual hospitalisation, ICU admissions and deaths, respectively.

Table 22: Total estimated cases prevented and associated healthcare outcomes for original, worst- case and best-case scenarios Cases Hospitalisations ICU admissions Deaths

Scenario n Lower Upper n Lower Upper n Lower Upper n Lower Upper

Original 353 306 409 24 16 36 5 3 6 14 11 19

Worst-case 157 139 176 12 8 20 3 2 4 9 7 12

Best-case 2252 1712 2986 65 48 91 9 7 12 32 25 41

Conclusions: As a result of the whole area testing pilot in Merthyr Tydfil, cases (both asymptomatic and symptomatic), hospitalisations and deaths, that would have otherwise occurred, were prevented. When taking into account multiple generations of infections that would have occurred in the community, over one tenth of cases that would have occurred over a 6 week period were prevented. This forecast translates into a predicted reduction of 6-12% in burden on the healthcare system. These results were obtained for a conservative, but probable scenario. However, in a less-conservative, best-

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case scenario, the number of prevented cases could be as much as three quarters of the actual case count, and a reduction of 18-23% in burden on the healthcare system.

It is likely that the whole area testing pilot in Merthyr Tydfil had an immediate impact on the level of SARS-CoV-2 circulating in the community, and would likely have contributed to the subsequent decline in COVID-19 case rates which occurred following the testing pilot and the introduction of the national lockdown, implemented on 19th December.

Recommendations: Further analysis of the costs avoided by the mass testing, in terms of cost per hospitalisations or ICU admission, relative to the cost of the mass testing exercise will provide further insights into the benefits of LF mass testing from a health economics perspective.

8.5 ECONOMIC EVALUATION OF MERTHYR TYDFIL MASS TESTING

Summary: A cost effectiveness analysis of the mass testing programme was carried out in Merthyr Tydfil. This involved attaching cost and QALY estimates to the modelled cases, hospital admissions, critical care admissions, and deaths prevented or postponed by the programme, and comparing these with the intervention costs of the programme. Overall the programme was highly cost effective with an estimated incremental cost effectiveness ratio (ICER) of £2,292 per QALY.

Methods: Standard cost effectiveness analysis (sometimes called cost utility analysis) methods were used.48 Appendix49 shows more detail of cost and QALY estimates. There have been several attempts to attach costs to COVID-19 outcomes.50 A ‘bottom up’ method was used, with Wales-specific medical costs and intervention costs collected as part of the mass testing pilot. The cases, hospital admissions and deaths were multiplied by estimated costs and QALYs lost. The QALY losses from COVID-19 cases included cases, deaths, hospital admissions and a conservative (low) estimate of the lost QALYs from long COVID, assuming that 10% of cases have COVID-19 symptoms for 12 weeks or longer.

The programme costs for the mass testing pilot in Merthyr Tydfil were estimated as £515,688. Costs were measured in GBP, at 2020 prices. QALYs lost from COVID-19 deaths were discounted at 1.5% per annum in line with UK Treasury Green Book. Other costs and QALYs were not discounted as they were assumed to occur within-year. Table shows the estimated outcomes and unit costs and QALYs for each outcome. No costs were assumed for cases that do not end in hospital or dying.

48 Drummond MF, Sculpher MJ, Claxton K, Stoddart GL, Torrance GW. Methods for the economic evaluation of health care programmes. Oxford university press; 2015 Sep 25. 49 Detailed methods and costs (see appendices) 50 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/907616/s0650- direct-indirect-impacts-covid-19-excess-deaths-morbidity-sage-48.pdf

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Table 23: Outcomes, QALYs and costs per unit.

Outcome Mid Low High QALYs lost Costs per estimate estimate estimate per case case (£) Cases prevented 353 306 409 0.0159 - Hospital cases prevented 24 16 36 0.0113 7,085 ICU cases prevented 5 3 6 0.0346 22,198 Deaths prevented 14 11 19 6.78 232

Results

The programme was highly likely to be cost effective, with an incremental cost effectiveness ratio of £2,292 per QALY gained (lower confidence interval: £905, upper confidence interval: £4,179). Net monetary benefit for the intervention, which is cost savings plus the value of QALYs gained (valuing discounted QALYs at UK Treasury £60,000) was £5.8million (£4.4m – £8.0m). See Table 24.

The majority of benefits (87%) are through the discounted QALYs lost and costs of people dying from COVID-19 (see Table 25). As a sensitivity analysis, we varied the QALYs lost from early deaths down from 6.78 down to 5 QALYs, but the net monetary benefits were still large at £4.3million. We also had a sensitivity analysis where we varied the value of QALYs down from £60,000 to £30,000 but the net monetary benefit was still positive at £2.8million. Using a 3.5% discount rate for health benefits (as recommended by NICE) instead of UK Treasury 1.5% slightly decreased the net monetary benefit from £5.8million to £5.4million.

Table 24: Estimated QALYs gained, cost savings, incremental cost effectiveness ratios (ICERs) and net monetary benefit of mass testing programme in Merthyr Tydfil, for mid, high and low estimate of effectiveness.

mid low high QALYs gained 101 80 136 Net costs (£) 231,420 333,188 123,046 ICER (Incremental cost effectiveness ratio) cost per QALY gained (£) 2,292 4,179 905 Net monetary benefit (valuing QALYs at £60,000) (£) 5,826,889 4,450,361 8,032,830 Sensitivity analysis Net monetary benefit - worst case model parameters (£) 3,463,211 2,576,674 4,788,774 Net monetary benefit - best case model parameters (£) 15,379,083 11,834,597 20,016,693 Net monetary benefit with lower QALY loss for COVID-19 deaths (£) 4,331,689 3,275,561 6,003,630 Net monetary benefit valuing QALYs at £30,000 instead of £60,0000 (£) 2,797,735 2,058,586 3,954,892 Net monetary benefit (3.5% discount rate instead of 1.5%) 5,364,889 4,087,361 7,405,830

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Table 25. QALYs gained and cost savings for mid, low and high scenarios of mass testing intervention in Merthyr Tydfil. Negative cost savings indicate net costs.

QALYs gained Cost savings (£) mid low high mid low high Cases 6 5 6 - - - Hospital cases 0 0 0 311,725 226,709 446,333 ICU cases 0 0 0 155,384 110,989 199,780 Deaths 95 75 129 5,336 3,944 6,728 Programme costs -515,688 -515,688 -515,688 Total 101 80 136 - 43,243 - 174,046 137,153

Conclusions: The intervention was very cost effective with a central estimate of £2,292 per QALY gained. This compares favourably with cost effectiveness thresholds such as the quoted National Institute for Health and Care Excellence (NICE’s) threshold of £30,000 per QALY gained, or the health production cost for the NHS in England, which is said to be around £15,000 per QALY gained.51 Even with pessimistic assumptions, the intervention is likely to be cost effective with a worst case scenario of £5,678 (£3,341 - £8,288 per QALY). We have been quite conservative and not included costs of non- hospital cases or long COVID cases, and the QALY losses from long COVID cases are also quite conservative. ICERs tell us about the ratio of benefits which might be expected to scale if the intervention was introduced somewhere else; we also estimated net monetary benefit which tells us about the absolute level of benefits we expect for this particular programme. The central estimate of net monetary benefit was £5.8 million which means a benefit:cost ratio of around 11 for the £516,000 that the programme cost, or a return on investment of around £10.30 per £1 spent. This is in line with the finding that public health interventions often have a high return on investment.52

The true costs and QALYs lost from COVID-19 are likely to be higher than these estimates as they do not include post-hospital rehab, the likely full implications of multi organ damage, productivity or informal care costs. The indirect opportunity costs for people whose NHS treatment is delayed because of treating COVID-19 patients is not included. There are likely to be lots of complex dynamic effects that are difficult to predict. Even for the costs and QALYs we have included, there is likely to be a large degree of uncertainty. The costs and QALYs are estimated for the population as a whole, however we know that direct COVID-19 harms are highly likely to be experienced more by people of low socioeconomic position, but that indirect harms of the COVID-19 response are also likely to be unequally distributed as well.

There are other onward costs of the COVID-19 system that are not included in this such as the costs of contact tracing, but these would fall both onto the intervention costs side, and on the cost savings

51 Claxton K, Sculpher M, Palmer S, Culyer AJ. Causes for concern: is NICE failing to uphold its responsibilities to all NHS patients? 52 Masters R, Anwar E, Collins B, Cookson R, Capewell S. Return on investment of public health interventions: a systematic review. J Epidemiol Community Health. 2017 Aug 1;71(8):827-34.

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side of any cost effectiveness equation, because preventing cases would reduce the need for future contact tracing.

The productivity losses from COVID-19 cases, hospital and deaths, or productivity losses from individuals self-isolating are not included. It is important to note that these interventions only work because individuals choose to reduce their contacts after testing positive for the virus. The informal care costs of people caring for loved ones who have COVID-19 are not included. If we included estimates for these the benefits would likely be greater and the intervention would be more cost effective. The equity impacts in the calculation of costs and benefits are not included; Merthyr Tydfil has a deprived population so adding an additional weighting for equity would likely mean that the benefits would be greater,53 however it may also mean that people are exposed to more competing risks of morbidity and mortality. The benefits to individuals in Merthyr Tydfil from employment in supporting the mass testing programme are not included.

A probabilistic sensitivity analysis or vary the economic parameters except in one-way sensitivity analyses was not carried out; so the range of results is influenced only by the upper and lower estimates of the epidemiological modelling.

This study has demonstrated that mass testing is likely to be cost effective.

Recommendations: 1. Further analysis of the costs avoided by the mass testing, in terms of cost per hospitalisations or ICU admission, relative to the cost of the mass testing exercise will provide further insights into the benefits of LFD mass testing from a health economics perspective. 2. It will be useful to compare with economic evaluation of other mass testing pilots such as in Liverpool and other parts of the world. 3. Further analysis could look at the threshold of community prevalence at which mass testing becomes cost-effective.

8.6. WASTE WATER TESTING

A brief overview of purpose: The frequent monitoring of coronavirus levels at wastewater treatment plants can offer a signal of the infection rate in the community and provide an early sign that coronavirus is present54. Wastewater testing was commissioned to inform the selection of Asymptomatic Test Sites and to provide evidence of changes in the infection rate in various parts of the county over the period of the pilot. The project team carried out wastewater sampling and analysis to monitor SARS-CoV-2 in the Merthyr Tydfil Borough sewerage system during the testing period and for a short time afterwards (30th November 2020 – 8th January 2021).

Methods used:

53 Collins BJ, Griffin S, Asaria M, Capewell S, Love-Koh J, Kypridemos C, Pearson-Stuttard J, O'Flaherty M, Cookson R. How Do We Include Health Inequality Impacts in Economic Analysis of Policy Options? 54 Welsh Government https://gov.wales/pilot-programme-measure-coronavirus-prevalence-waste-water- treatment-plants

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The Welsh Government had already commissioned wastewater testing from sites around Wales to assess the spread of coronavirus.

To inform the Merthyr pilot, the Welsh Government brought together partners involved the existing wastewater testing project: Bangor University, Cardiff University, Dwr Cymru Welsh Water (DCWW) and the Joint Biosecurity Centre (JBC). Bangor University and the JBC had previously been involved in wastewater testing in support of the Liverpool pilot of community testing. Further detailed planning meetings with DCWW involved analysis of GIS and sewerage network maps to identify appropriate sampling points based on LSOAs across the Merthyr Tydfil Borough.

Partners collaborated to select seven network points (Figure 38) as the key daily sampling sites. DCWW undertook on-the-ground inspection and risk assessment to confirm the suitability of the sites.

Four of the seven wastewater network sampling sites were in Merthyr Tydfil town areas, and were selected to take into account areas of economic deprivation (e.g. Pant, Galon Uchaf and Gellideg) and the Prince Charles Hospital.

Figure 38: Locations of sampling sites (green circles) mapped onto Merthyr Tydfil Borough LSOAs, indicating relative levels of deprivation (see key)

The two other network sampling sites were:  a site down the valley (Abercanaid) providing an ‘integrated’ sample of wastewater coming from Merthyr Tydfil town; and  a site sampling wastewater exclusively from Aberfan.

In addition, Cilfynydd wastewater treatment works (WwTW), which takes all of Merthyr Tydfil Borough’s wastewater, was selected for daily sampling.

Partners tried, as far as possible, to identify sampling sites that minimised disruption, but some of the sites required street works and/or traffic management controls.

DCWW appointed contractors to undertake the wastewater sampling.

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The costs of wastewater testing were met by Welsh Government. Costs included:

Wastewater sampling: approx £2,500/week;

Consumables (reagents, robotics, materials, etc.) cost per sample, ca. £56. Thus, processing daily samples from 7 sites (49 samples x £56), £2,800/week; and

Staff, analysis and indirect costs, £4,900/week.

Total approx. £10,400/week

Total cost for 6 weeks approx. £62,400

Concerns identified/lessons learned:

 There needs to be a long lead in with regard to planning to enable sampling sites to be identified, traffic management arrangements made, sampling plans and analysis.  The capacity and timing of analysis and the interpretation of results needs to be timely in order to inform sampling locations.

What went well? Partners were approached at short notice and reacted very positively to the request, collaborating effectively to identify and assess suitable sampling sites, making arrangements for sampling and the analysing samples.

The co-ordination of sampling (DCWW) and testing (Cardiff University) teams worked well in terms of delivery of samples and processing/analysis through the period of the Pilot, particularly given the challenges around resources available and with working through December and the Christmas period.

The results showed that although differences were evident in the levels of SARS-CoV-2 from the wastewater network sampling sites, indicating variation in COVID-19 positive cases in sub-populations living in different areas of the Merthyr Tydfil Borough community (Figure 38), the differences were not significant.

Single, daily grab samples from Merthyr Tydfil and Aberfan wastewater network sites representing relatively low populations (range ca. 2,500-3,600) produced highly variable stochastic data (not shown), which so far has not been tractable with the various modelling approaches used (see below).

However, when the data were averaged on a 7-day basis, all of the sites showed a trend of increasing wastewater virus signal through the period of the community testing, with a slight decrease post- Christmas (Figure 39A).

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Figure 39: SARS-CoV-2 signal in wastewater from Merthyr Tydfil Borough sampling sites during community COVID-19 testing period. (A) Weekly averaged SARS-CoV-2 at seven sampling sites (see Figure 38) across the Borough; (B) box-whisker plot comparing between site SARS-CoV-2 levels during the sampling period.

What could be improved? The Pilot highlighted for the first time a number of issues linked to the inherent variability of wastewater SARS-CoV-2 signal. It is now evident that the data are highly variable in wastewater networks serving relatively small populations (<10,000) by comparison with larger towns and cities (>100,000), producing spikes in the daily data and making results more difficult to interpret.

For example, in this pilot the total population of Merthyr Tydfil Borough (ca. 62,000) is about the size of the population associated with the smallest wastewater network sub-catchment that was sampled in the Liverpool pilot. Relatively small wastewater sub-catchments, such as those in Merthyr Tydfil, would be better sampled, by higher frequency grab sampling. Composite sampling could also be considered in some cases, but is likely to be more difficult from an operational perspective.

Conversely, in areas with larger populations, wastewater network sampling would potentially be easier, because of the increased availability of more convenient sampling sites (e.g. associated with pumping stations and Combined Sewer Overflows), and other resources.

Selection and assessment of sampling sites, appointment, training and instruction of a contractor all took time. Sampling at the majority of sites began 10 working days after assistance was requested, although sooner at some. Therefore, wastewater data were not available to inform the selection of Asymptomatic Test Sites.

This matter could be addressed by pro-actively identifying sub catchment sampling sites in locations where community testing may be deployed in future. Partners would be willing to collaborate to identify suitable sites if Welsh Government were to commission a study. There would a cost for this work.

The processing of wastewater samples and analysis to provide results required more time than originally anticipated. This meant that data were not available in near enough real time during December to help guide community testing. The pipeline for processing and analysis at Cardiff

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University is now more automated and faster. Therefore, it is anticipated that in future wastewater monitoring would be of greater utility during the testing and, potentially, in a pre-testing period.

Conclusions: Partners had been keen to support the use of waste water sampling to inform community testing undertaken during the pilot. The results of the waste water sampling were not available at the time of the pilot to inform the location of sampling. However, the results did show a potential to provide information about the relative burden of COVID-19 infection and may benefit from further research. Compared with that of larger towns and cities (>100,000), data were found to be highly variable in wastewater networks serving relatively small populations (<10,000), producing spikes in the daily data and making results more difficult to interpret. The results confirmed that wastewater testing has potential to provide information about the prevalence of COVID-19 to inform the selection of Asymptomatic Test Sites. Lead times of several days are necessary to identify and assess suitable sampling sites, regular sampling, processing and analysis. In addition, reporting procedures need to be more streamlined and nearer real time for wastewater data to help inform testing strategies.

Recommendations:

1. Monitoring of SARS-CoV-2 in the wastewater network provides additional independent and useful information regarding the presence of the virus in the community, which is independent of whole area testing. 2. Timely planning meeting(s) with appropriate representation from all team partners (not only those primarily involved in wastewater monitoring), reasonably in advance of start of whole area testing, are essential to focus on sampling site identification – taking into account factors such as network configuration, relative ease of access (manholes, CSOs, pumping stations, wastewater treatment works, etc.), special sites (e.g. hospitals, prisons, large businesses/schools/institutions, etc.). 3. Number of sampling sites, sampling frequency and types of sample (grab/composite) need to be calibrated and ensured suitable for area/population. 4. Maintain coordination and communication between all team members before, during and after the whole area testing window. 5. Ensure dedicated wastewater monitoring operations team pipeline from sampling through sample processing and analysis to allow results to be obtained and shared in as close to real time as possible; i.e. initial results within 4-5 days of sampling. 6. Confirmed results should be used for higher level analysis, e.g. contextualised and correlated wherever possible with COVID-19 testing and other appropriate public health metrics for the area/population undergoing testing. 7. Continued development of methodologies for wastewater sampling, and processing and analysis of samples suitable for the range of communities across Wales; i.e. urban (large, high-density populations, excellent wastewater network connectivity), peri-urban (medium-sized, variable density populations, good wastewater network connectivity) and rural (relatively small, low density populations, variable or poor wastewater network connectivity) communities.

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9. COMMUNICATION AND ENGAGEMENT

9.1. MERTHYR TYDFIL

A brief overview of purpose: A comprehensive communications and engagement plan was an essential component of the planning process and fundamental to the success of Whole Area Testing. A campaign strategy11 outlined the ways in which Merthyr Tydfil County Borough Council would engage with residents and partner organisations to encourage uptake of the mass testing programme. Key messages: 1. Testing is free and available to everyone 2. It is both safe and convenient to get tested 3. Taking a test will help prevent the spread of COVID-19 4. The programme's success depends on a community-wide effort

In terms of the uptake required, 30% was considered too low, 50% the minimum and 80% a good, but a high (possibly unrealistic) target.

The campaign Key Performance Indicators (KPIs) are: - 10,000 accumulated instances of digital engagement (to include: likes/equivalent, shares/equivalent, comments, reach) - Minimum 1 feature in 5 regional publications (To include: local news channels, regional papers/their websites)

Methods used:

The campaign reflected the efforts of other regional testing pilots (such as those in Liverpool). It was be divided into 2 phases: PHASE 1: Announcement; PHASE 2: Testing is live.

Primary - An accessible, emotive, digital-first approach (to include: some paid advertisement, influencer endorsement and appropriate use of social networking platforms)

Secondary - Offline engagement (including traditional media: printed literature, offline advertising, etc.)

Assets used:  Marketing  Community Leaders and influencers  Further assets were developed for sharing through Facebook, Twitter and Instagram, in the form of three stories, the purpose of which were to counter potential obstacles to testing which have been identified through other pilots.  How testing works  Incentives – This was considered later in the process as the testing uptake was high. The reason it was focussed on it towards the ends of the process was to try to engage more with the 16-24 year olds. This was done by asking people to share and like our posts on social media with the lucky winner being offered a family ticket for a Swansea City and Cardiff City Football game.

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Concerns identified/lessons learned: There were no major concerns as such just a few observations.

What went well?  In the early planning process Liverpool Communications Team were contacted to get their views on their experiences and what they would have done differently. This assisted massively with the communication strategy, especially with a short leading time before launching the programme.  Good Relationships with partners, including Merthyr Tydfil County Borough Council and CTMUHB, was key to the delivery of effective communication and engagement. Daily touch point meetings via ‘Teams’ with WG, Central Government, the Health Board and the Military provided a good network of support and resources.  The strong relationship with the Military from the outset proved highly beneficial in relation to the overall delivery of the programme. These clear channels of communications, particularly around the initial planning, gave an early insight to how the programme would operate.

What could be improved?  More leading time to plan the communications strategy before the start of the programme  More resources to deliver the programme  As the lead organisation, having more control over the communications being developed by other partners.

Conclusions: All in all the communication and engagement strategy did achieve the required outcomes of getting a high level of the population tested. Throughout the testing programme, a close watch was kept via social media channels on what the public were saying and their experience of the testing centre. As a result of this, there was the continual ability to adapt the communication strategy to keep people updated and responding to their queries and concerns. With all the media interest at the start of the pilot and those eager to attend the testing, initially there was no need to try hard to encourage people to get tested. After this initial rush, things slowed down and it was clear that the 16-24 year olds, self-employed people and those working, who did not want to self-isolate were reluctant to get tested.

At this point a different approach was required to encourage these groups to get tested was needed.

To do this large employers were engaged with to get their workforces fast-tracked and tested in large groups at test centres close to their place of work. Work was also undertaken with local influencers to assist with the engagement of the 16-25 year olds, e.g. a local gym instructor who had over 300 members and was very popular within the community.

Knowing your own communities and how to engage with them is key to the success of participation to the programme. For example, the Valleys people are very different to those that live in a city. Everyone is very close and know each other. This worked to our advantage and as one of the largest employers in the town, the Council were also able to use their staff to promote the importance of getting tested and encourage them to attend.

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9.2. LOWER CYNON VALLEY

A brief overview of purpose: The lower Cynon Valley campaign reflected the efforts of other testing pilots (such as those in Liverpool and Merthyr Tydfil).

Methods used: It was divided into 4 phases:

1. Announcement 2. Getting ready 3. Testing is live 4. Maintaining momentum

The main form of media used were:

 Door-to-door leafleting  Business leafleting  Social media (videos/graphics)  Paid for social media advertising  Website  Press releases/media buy-in

Digital media was the primary form of communication for the campaign, as it allowed regular communication with residents, as well as providing timely information.

Social media was the most utilised tool in the campaign due to its immediacy and flexibility, allowing for changes to be communicated to residents with relative ease, as well as its in-built tools for targeting specific geographical areas.

Physical media, in the form of leaflets, was also provided to residents and businesses in the lower Cynon Valley area. This allowed for people to have a physical copy of the information to hand if required, and also to allow residents who don’t use social media, especially older residents or those with low digital literacy, to make an informed decision on Mass Testing and encouraging attendance.

What went well? Daily meetings and communication with partners in Merthyr Tydfil, Cwm Taf Morgannwg UHB, and Welsh Government meant that partners were continually aware of operational activities, as well as any operational/communications issued that arose. Large volume of social media posts and paid-for social media advertising ensured that Mass testing had a high visibility on social media platforms.

Walk-through videos were used on social media to highlight the testing process. These were well received by people who could familiarise themselves with the process, as well as seeing the safety measures put in place to protect the public.

Positive messaging was used throughout the campaign to encourage attendance, using inclusive language and promoting the benefits of getting tested, as opposed to the negatives of not being tested. This helped to create positive engagement on social media platforms, with people commenting how they have ‘done their bit’.

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On social media, some answers to frequently asked questions were scheduled as part of the communications campaign, which also included a link to more frequently asked questions on our website. This allowed for people to find answers for themselves without asking the communications team. It also allowed the communications team to direct questions to the website when asked, with an approved message, for people to find the answer themselves, saving time.

When messages were posted publically on social media posts, regarding people not receiving test results or other negative experiences, individuals were encouraged to send a private/direct message to look further into their experience. By doing this, the team was able to divert negative attention away from the public sphere and resolve directly with an individual. This was helpful when dealing with a crucial public health intervention, especially one that is subject to deliberate misinformation and subversion. The public can be sensitive to negative experiences, which risks eroding trust and preventing people from engaging with mass testing.

Regular updates were provided on the amount of people who had been tested throughout the day, with a total provided at the end of the day, which included the number of positive tests and how many people had been tested in total. These were essential, as these figures were frequently asked for by individuals and also allowed the media to access the figures without having to contact the communications team.

What could be improved?

Partnership Working As Whole Area Testing in Merthyr Tydfil was first to begin, in the first instance, the focus of partners was solely on delivering this element of the Mass Testing. There appeared to be a reluctance to acknowledge that Whole Area Testing in the lower Cynon Valley would be taking place until all elements of the Merthyr Tydfil Whole Area Testing were finalised. This meant that the communications team at Rhondda Cynon Taf were working in parallel with the communications team at Merthyr Tydfil.

Rhondda Cynon Taf were grateful to Merthyr Tydfil for continuing to share key documents, literature and assets during the Whole Area Testing pilot, which were used as a basis for the communications strategy for the lower Cynon Valley.

Upon reflection, it was a missed opportunity for the communications teams in Merthyr Tydfil and Rhondda Cynon Taf to create a joint communications strategy, as well as joint assets, literature and branding.

Door-to-door leaflets, testing centre brochures, social media assets are all examples of where it would have been beneficial for both Merthyr Tydfil and Rhondda Cynon Taf communications teams to work in partnership to save time and duplication of work, allowing teams to focus on local messaging.

Since the beginning of the COVID-19 health emergency, Merthyr Tydfil and Rhondda Cynon Taf, alongside Cwm Taf Morgannwg UHB and Bridgend, have worked extensively on COVID-19 communications on a regional basis, which has been very successful.

Partnership working during this time has been beneficial, allowing for pooling knowledge and resources, creating a regional identity, a shared ‘voice’ on important messages, as well practical benefits such as relieving staffing pressures and time-constraints.

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Given the pressures on communications teams at this time, with the extensive and genuine partnership working that has occurred throughout the pandemic, and the in-house experience between the two Local Authorities to deliver complete communications campaigns, it would have been beneficial for all involved to approach the WATP in Merthyr Tydfil and the lower Cynon Valley as two phases, as opposed to two separate events.

Defining Areas It’s important to remember that communities/urban areas in Wales are sometimes difficult to split into administrative areas, or that the various administrative areas (electoral wards, constituencies) are not always consistent with geographic areas. Defining areas in this way can lead to lines being drawn through communities, and can confuse people which was the case with Aberaman South included in the pilot, whereas Aberaman North was not included. This led to people frequently asking if they lived in the pilot area, and negative feedback from people who lived within sight of the eligible area.

Furthermore, the pilot area was described as the ‘lower Cynon Valley’ but excluded the communities of Ynysybwl/Glyncoch which actually fall within the Cynon Valley constituency, on the border with the Pontypridd constituency. By the constituency definition, this would be the ‘lower Cynon Valley’, and this led to negative feedback from those communities who felt they were excluded at a time when cases in those communities were at high levels.

As well as the local area, people from across the County Borough were questioning when it was being introduced in their area. This was an ongoing theme throughout the WATP.

Leaflet Delivery Due to the tight timescales involved in promoting the lower Cynon Valley pilot from confirmation to start of testing, door-to-door leaflet distribution was unable to be handled by an external company. This meant resource was sought internally from within the Council to deliver these. The team successfully delivered the leaflets by the start of the WATP, however, it was a significant logistical challenge to ensure a sizable body of staff to do the delivery and required members of the communications team to coordinate the deliveries, reducing capacity in the team. This could have been avoided had there been sufficient time to send these out to our delivery partners to handle the logistics.

Local Authorities are used to sending mass communications to residents and businesses, and have systems in place to do this, as is the case with annual Council Tax and Non-Domestic Rates notifications, electoral information and service changes. However, sufficient time is needed to achieve this, and factoring this into the planning process should be considered at the earliest opportunity.

Conclusions: From a communications perspective, it can be judged that the lower Cynon Valley Whole Area Testing pilot was a success. An asset bank of all media communication is available in the lower Cynon Valley Whole Area Testing Asset Bank55:

55 Lower Cynon Valley Mass Testing Asset Bank: Includes social media assets/videos, posters, testing brochures, leaflets, signage, social media analytics, and media inclusion list (see appendices)

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Looking at social media analytics, it highlights a high level of visibility for the campaign, as well as a genuine interest by people to click through onto our website to find out more information.

 Reach: 5.3m  Retweets/Shares: 1,900  Likes: 3,100  Comments/messages: 1,300  Link clicks: 7,900

Feedback from those that attended was extremely positive, with positive messages from visitors received several times a day throughout the testing period. Praise was mostly on the knowledge and friendliness of staff, the speed in which the tests were conducted, and the measures put in place to keep visitors safe.

There was some negativity posted on social media channels, however this was mostly unrelated to the operation of the WAT. Negative comments were focused on questioning the reliability of the LFD tests, whether COVID-19 really exists, with a few complaints from individuals who had failed to receive their test results, although this was small in comparison to those tested

It must be stressed, that many of these negative comments were made by the same individuals, and also individuals who on social media have consistently spoken out against coronavirus restrictions, the existence of COVID-19 and have been hostile to any information that has been provided about coronavirus.

Paid for advertising helped to focus messages at a hyper-local level, especially where a test centre was open for a limited period of time in one location.

The communications teams in Merthyr Tydfil and Rhondda Cynon Taf responded flexibly to operational changes, such as the extension of the pilots. The teams delivered comprehensive communication campaigns, utilising a wide-variety of media to promote and encourage attendance at testing centres and ensured as many people as possible were exposed to a range of digital and physical promotion.

A special thank you to the communication colleague at Welsh Government who provided an exceptional level of support during the pilot.

Communication recommendations: 1. Establish a good working relationship with partners early on in the process and meet regularly. Communication teams should be involved in the testing planning process from the earliest opportunity so they can understand the testing process, the operational delivery of testing, provide communications advice and limitations, allowing sufficient time to create all content and its delivery, as well as receiving sign off by partners. 2. Clearly define the testing area before announcing and aim to place this within a clearly defined area, which does not cause confusion or cut through communities. 3. Where a testing area is defined across Local Authority boundaries, it should be approached as one event, whether they occur at the same time or one at a later date. This will allow a whole area approach to testing and not viewed as separate events. 4. Local communication teams know their communities the best and should be confident to challenge decisions made by others.

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5. Use of local influencers to instil trust and confidence in the process. Also, use these individuals to highlight the consequences of transmission of the virus. 6. To be able to deliver a comprehensive communication and engagement strategy, sufficient leading time and the relevant resources are needed. 7. Have a point of contact at each location so that you can provide regular updates to the public. 8. Be open and transparent in relation to the number of tests undertaken and the results. 9. Engaging with businesses is important, communicating the need for staff to get tested to ensure the safety of their colleagues and customers, but also the benefits to business continuity and ensuring a large number of staff do not need to self-isolate or risk becoming infected. 10. The need for agreed messages to resolve any operational queries that are received, such as when an individual doesn’t receive their test results, as well as for frequently asked questions.

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10. OPERATIONAL RESEARCH FOR RISK FACTORS IN TRANSMISSION INCLUDING BEHAVIOURAL INSIGHT

10.1. CASE CONTROL STUDY

A brief overview of purpose: There is limited information on what factors are currently driving SARS-CoV-2 transmission in the community in Wales. Having a better understanding of these, could help tailor interventions to reduce transmission. The Whole Area Testing pilot presented an opportunity to conduct an epidemiological study. The aim of this study was to identify social and demographic factors associated with infection in a high incidence community, in order to inform prevention and control.

Methods used: An unmatched case-control study in adults (18 and over) attending the WATP for at least one LFD test was carried out. Cases were all people with a positive LFD test result, controls were a sample of those with a negative LFD test result. A questionnaire was designed in the software tool Smart Survey, which included 37 questions on demographic and social risk factors. These included: age; ethnicity; occupation; area of residence; people who you share a household with; caring responsibilities, and social interactions in previous 10 days. All newly tested individuals with a positive result (cases) were sent a text message through the government portal texting service ‘notify.gov’ asking them to complete a short anonymous self-administered on-line questionnaire in Smart Survey. For each case, we randomly sampled 10 individuals who were tested on the same day but had a negative test result (controls). In order to distinguish between cases and controls, a different link was sent to each group (See text message and questionnaire in the full report56).

Response rates for cases and controls were calculated. Univariate and multivariate logistic regression analysis was carried out using Stata v 14. Odds ratios with 95% Confidence Intervals were calculated for exposure variables.

Concerns identified/lessons learned:

Practical issues in recruitment into the study This study was rapidly designed and implemented. Initially recruitment was planned at each testing site. Cases and controls were to be asked to scan a QR code whilst attending. This approach proved impractical, and risked obstructing the main purpose of the WATP. Also there were a number of practical issues in relation to identifying positive cases, as participants were encouraged to leave the testing site whilst awaiting text notification of their test result. The eventual recruitment strategy was via text to personal mobile phones. This provided contactless recruitment, reducing health and safety risk to the field epidemiologists involved. Early text messages sent to the lower Cynon Valley Residents only referred to the Merthyr Tydfil pilot and this created negative feedback to the Local Authority. The text messages were amended rapidly by PHW to include reference to both testing areas.

56 Merthyr Case Control Study (see appendices)

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Data privacy and information governance As recruitment was through direct text to personal mobiles, information governance advice was obtained. This epidemiological study was carried out to inform the ongoing epidemic response; and as such was covered by Public Health Wales’ Establishment Order; and the COVID-19 privacy statement (see the relevant section below, and the full statement here).

What went well?

Collaborative approach The study was led by Public Health Wales Communicable Disease Surveillance Centre. Throughout the study we obtained excellent input and engagement from colleagues in Local Authorities, TTP, Welsh Ambulance Service Trust and the Cwm Taf Morgannwg University Health Board. During the planning process we joined a site visit to Merthyr Tydfil leisure centre and found everyone to be constructive and highly supportive of us carrying out an epidemiological study.

Statistical power From previous mass testing exercises, prevalence was expected to be below 1%. Power calculations were carried out in advance, but there were concerns that if response was poor, particularly amongst positive cases, the study would not be powered sufficiently to identify statistically significant risk factors. In the event this was not the case: With 30% response we recruited nearly 200 cases and over 2,000 controls, enabling identification of odds ratios less than two.

Recruitment via text message Use of Notify government text service to recruit participants worked well. Individuals were contacted using the mobile phone number which they provided when they attended screening. Notify is a UK Government run platform which is a secure mass texting service. Notify is compliant with the Data

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Protection Act and any user data uploaded (e.g. phone numbers) are deleted after 7 days. Data which passes through the system is encrypted.

Notify has been assessed and approved by the Cabinet Office Senior Information Risk Officer (SIRO). The SIRO checks this approval once a year. Notify is suitable for sending messages classified as ‘OFFICIAL’ or ‘OFFICIAL-SENSITIVE’ under the Government Security Classifications policy.

Results of the case control study This study provides an insight into the most important factors determining community transmission of SARS-CoV-2. We found that transmission within the household was the most important source of SARS-CoV-2 infection. Working in the hospitality sector, and visiting the pub were significant risks but at the time of this study were relatively infrequent exposures. Smoking or vaping had a small but significant effect. Working in education, living with someone working in education, having caring responsibilities and visiting a supermarket, restaurant, gym or leisure centre did not appear to increase risk of infection. This provides information for local action and to inform policy decisions.

What could be improved?

Questionnaire design The questionnaire was designed quickly. Although we piloted the questionnaire on a small number of individuals, including school nursing staff working in the heath board area, it would have benefitted from some further piloting prior to implementation.

Improved access to data on Lateral Flow Device test results Recruitment was carried out using the data collected at registration and test results. These data came to Public Health Wales from DHSC in England via NHS Wales Informatics Service. Obtaining these data in a more timely way would have improved our recruitment process.

Conclusions: This proved a successful addition to the Whole Area Testing pilot. The results of this study have been used to inform the Community Testing Strategy in Cwm Taf Morgannwg. A full report is available as an appendix to this report (Appendix X). A manuscript is currently in preparation for submission to a peer-review journal.

Recommendations: 1. Whole Area Testing is used as an opportunity to carry out studies to answer specific questions relating to the epidemiology of COVID-19. 2. The results of the case control study are used to inform interventions to limit transmission of COVID-19 including communication with the public, testing strategies, advice to businesses and enforcement. 3. The study is published in a peer reviewed journal.

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11. COMPARISONS – LEARNING FROM OTHER AREAS The comparisons and learning from other areas relating to schools, is included in the schools section.

11.1. LIVERPOOL

A brief overview of purpose: The City of Liverpool and national agencies partnered to pilot community open-access SARS-CoV-2 testing for people without symptoms of COVID-19, living or working in the city. This was part of Liverpool’s COVID-19 resilience and recovery efforts, with an emphasis on reopening of activities key to social fabric and the economy, while controlling transmission of the virus57.

Partners set a mission to:

- Identify the virus, wherever it is in the City, and empower local communities to suppress its transmission while being supported well when they need to isolate or quarantine; - Identify those who are needlessly self-isolating and empower them to return to usual activities.

The goals were:

1) Saved lives and improved health outcomes for the City’s residents; 2) Saved livelihoods and businesses, protecting the City’s economy and social fabric; and 3) Sooner and safer reopening of the City as a whole.

Methods used: Pilot planning was overseen by Liverpool City Council COVID-19 Strategic Co-ordination Group with the Department of Health and Social Care in England (DHSC) ahead of the Command-and-Control system being activated on 6 November.

The DHSC, as pilot sponsor, provided the initial directive to the Military unit (8 Engineer Brigade) to establish 48 new asymptomatic testing sites (ATS) in the City of Liverpool using pre-purchased Innova lateral flow devices. Two Military staff were seconded to DHSC to act as liaison. The role of the DHSC during the pilot was to approve the location of test sites, provide financial indemnity for site operators, approve costings and establish an evaluation steering group.

Approximately 2,000 personnel from 8 Engineer Brigade arrived on Merseyside by 2 November and established an operational headquarters at HMS Eaglet in Liverpool. Liverpool City Council’s Assistant Director for Supporting Communities was designated as Military liaison officer, leading local negations over ATS and linking the Military into the Command-and-Control structure.

Six initial ATS were in Liverpool City Council premises as these could be approved quickly. Military personnel took responsibility for the buildings and set up the testing infrastructure (signage; registration desks; testing booths; queueing systems) on 5 November for start the next day. The selection and confirmation of the second and third phases of further sites for ATS required more complex negotiation with site owners and DHSC. The process was informed by combined intelligence from the CIPHA system and analytic expertise from Military, City Council and University partners.

57 Liverpool Covid-19 Community Testing Pilot Interim Evaluation Report 23 December 2020 (see appendices)

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To assess test performance, approximately 6,000 attendees received a pair of Innova SARS-CoV-2 antigen lateral flow device (LFD) and reverse transcription polymerase chain reaction (PCR) tests. Two supervised, self-administered swabs, first LFD, then PCR, were taken at the same appointment within minutes. The PCR test used was the standard test used in Lighthouse Laboratories. The results were sent from NHS Test and Trace to CIPHA and analysed by an independent team at the University of Liverpool.

Concerns identified/lessons learned: Testing most of a UK city’s population for COVID-19 on a ‘mass’ voluntary basis is not feasible. However, targeted testing has potential as part of an intelligence-led local public health intervention. The pilot team developed SMART (systematic, meaningful, asymptomatic, repeated testing), an alternative approach to mass testing. The key elements of SMART are: - test-to-protect (vulnerable individuals and settings), - test-to-release (sooner from quarantine), and - test-to-enable (safer return to key activities for social fabric and the economy).

During the pilot, 25% of 498,000 residents took up lateral flow device tests (LFDs) and 36% took up LFD or polymerase chain reaction (PCR) tests: - From 6 November to 9 December 25% of the Liverpool population took up LFD and 36% took up either LFD or PCR - 897 positive individuals were identified by LFD and 2902 by PCR. - The 897 individuals identified by LFD were not aware they were carrying SARS-CoV-2, they received notification to self-isolate and contact tracing was applied. - Between a fifth and a third of all SARS-CoV-2 cases detected in Liverpool week by week since 6 November have been via LFD, most recently 30% from 11-17 December. - Asymptomatic case and contact identification rose in Liverpool between 6 November and 9 December while the corresponding rates in neighbouring Greater Manchester region fell. - LFD and PCR uptake was lower in more deprived areas, where test positivity was higher. - LFD and PCR uptake was lower in men than women. - LFD uptake was lower in younger compared with older age groups. - Digital exclusion (proxy measure via area-based Internet User Classification) was a strong predictor of poor uptake of LFD and PCR. - 1km longer walk distance to ATS was associated with 5% reduction in LFD uptake, after controlling for age, deprivation, and digital exclusion. - At present, there is no clear evidence that that the introduction of community testing led to a change in COVID-19 case incidence or hospital admissions in Liverpool.

The Innova SARS-CoV-2 antigen lateral flow device sensitivity was lower than expected (based on the preceding validation studies) at 40% but identified two thirds of cases with higher viral loads (~Ct<25). - Sensitivity (true positive rate) = 40.0% (28.5% to 52.4%; 28/70) - Specificity (true negative rate) = 99.9% (99.8% to 99.99%; 5,431/5,434) - Positive predictive value (post-test likelihood of PCR +ve = 90.3% (74.3% to 98.0%; 28/31) - Negative predictive value (post-test likelihood of PCR -ve = 99.2% (99.0% to 99.5%; 5,431/5,473) - Predictive values depend on the prevalence in the asymptomatic population, which changes over time. A prevalence 1.3% was considered of SARS-CoV-2 infection among asymptomatic individuals using this dataset, which is consistent with ONS estimates for

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the period. Comparison of the LFD site and QA results showed 5,862 concordant and 7 discordant samples (99.9% concordance).

Local knowledge and targeted communications, including tackling misinformation, were essential.

No firm conclusions can yet be drawn about the effects of a negative test on risk behaviours but the authors report no alarming indicators in survey results.

Supplementary mailing of home test PCR kits resulted in only 8.3% completion so was quickly aborted.

What went well? The speed of design and implementation of the pilot was challenging, but drew upon, and further strengthened, the local networks and collaborations delivering Liverpool’s COVID-19 responses. Military involvement was well-received by the public and by local operational teams.

A combined NHS, Local Authority, and public health intelligence system updated every 30 minutes, underpinned communications and testing operations.

Awareness of the pilot was high and attitudes towards it were generally positive. Collective identity and social responsibility were key motivators of testing uptake.

Asymptomatic case and contact identification rose in Liverpool during the pilot period while the corresponding rates in neighbouring Manchester fell.

What could be improved? LFD uptake in the most deprived areas was half that in the least deprived areas – 16.8% vs. 33.4% – and test positivity was double in the most vs. least deprived areas (1.0% vs. 0.5%). Digital exclusion was a substantial barrier to LFD uptake, more than deprivation alone.

Younger people, particularly males, were harder to reach than older people.

Fear of not having adequate support to isolate was a major barrier to taking up testing.

Half of secondary school pupils took up testing, impacted by negative media from outside Liverpool. Following a briefing on Thursday 8 November for secondary school head teachers to prepare for testing at schools, an opt-in consent process was agreed. However, one school (not at the briefing) misunderstood their school would begin testing on the following Monday and sent an opt-out letter to parents on the Friday. Although this was recalled and replaced with an opt-in letter on Sunday, it fuelled negative discussion on social media, which damaged uptake of testing at schools. Rates of consent varied considerably by school. An average of 52.6% of pupils at participating secondary schools (31 out of 33) were tested. A total of 32,411 tests (84% pupils; 16% staff) were done at schools.

Consultation with residents (via surveys and focus groups) identified that the MAST (mass, asymptomatic, serial testing) pilot terminology was not well understood. ‘Symptomatic’ and ‘serial’ proved especially challenging terms to communicate. There was insufficient attention to briefing those attending for testing that they should return within five to seven days for another test.

Misinformation may have affected public confidence and uptake. Misinformed issues included perception of the risk of infection at test sites, suspicion around Government use of data collected

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(especially ‘DNA’), and the need to have physical contact with centre staff. The communications team responded through a page on Liverpool City Council website, daily stakeholder emails; Facebook messages targeted by postcodes and regular press briefings and contact with ward councillors and community leaders. Public figures from the football and entertainment communities provided short influencer videos which were disseminated via social media channels.

Distribution of leaflets via pharmacy prescriptions bags was first discussed on 19th November. Targeted initiatives such as this would have been beneficial earlier in the pilot.

Community engagement proved challenging in the absence of an existing city-wide voluntary plan. Although the Liverpool Charity and Voluntary Services (LCVS) had some capacity to act as a liaison service, and knowledge of charities and neighbourhood groups, it proved impractical to mobilise these at such short notice to provide a community activation service. Liverpool City Council began a leafleting drop to targeted neighbourhoods on 20 November, after the main publicity drive, missing the opportunity for a critical mass of ‘push-pull’ communications.

Discussions around deploying third party vehicles as testing centres were hindered by health and safety/protocol/sign-off concerns so did not proceed. These would have been a very effective route into the hardest-to-reach communities that have poor digital engagement.

Conclusions: Currently, there is no clear evidence that the introduction of ‘mass’ testing in Liverpool impacted on COVID-19 cases or hospital admissions. Yet a third of Liverpool’s current detection of infected individuals is via LFD, picking up those without symptoms who would previously have not been tested. Longer term impacts will be reported later.

Recommendations: Large-scale, intelligence-led, targeted, and locally driven community testing for SARS-Cov-2, in concert with other control measures and vaccination, can support COVID-19 resilience and recovery. The time and scale gained from a low-cost, no-lab test can provide a useful additional COVID-19 control measure with targeted and clearly explained use.

Innova LFD is a helpful tool for finding asymptomatic cases of SARS-CoV-2, and in particular cases with a higher viral load. However, given its low sensitivity, caution should be exercised in how the device is applied, particularly in vulnerable settings where the consequences of infection are severe. Here, LFD should not be used as a direct replacement for PCR but as an additional tool for SARS-CoV-2 transmission control and risk mitigation. Repeated LFD may improve sensitivity but optimal series of tests for particular uses needs further study. Combinations of LFD and PCR testing also need investigation. The Liverpool Covid- SMART care home visiting protocol is testing the performance of two Innova LFD at different swabbing sites within 24 hours, the first accompanied by an evaluation PCR. Results of this initiative are due to be reported in early 2021.

11.2. SCOTLAND

A brief overview of purpose: The Scottish Community Testing Programme pilot aimed to assess whether targeted community testing, when combined with other measures, can help reduce community transmission by identifying and isolating positive cases that would otherwise be missed.

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The Programme is in addition to the expansion of asymptomatic testing programmes in Universities, Health Care and most recently a pilot in School settings and provides a reactive and targeted response to high prevalence and the need for enhanced testing in local areas to break the transmission cycle. It sits alongside the expansion of symptomatic PCR testing through additional Local Test Sites, Mobile Testing Units, Regional Test Centres, rural satellite hubs and improved home test kit coverage.

Methods used: Between 26th November and 9th December 2020, testing resources were targeted at eight communities in Scotland (Alloa, Clackmannanshire; Johnstone, Renfrewshire; Dalmarnock and West Pollockshields, Glasgow; Stewarton and Dalmellington, East Ayrshire; Girvan and Dalmilling, South Ayrshire) with high prevalence levels of COVID-19. This involved the deployment of six mobile testing units, over 4,000 home test kits and the establishment of an Asymptomatic Test Site and Military planning assistance58.

Concerns identified/lessons learned:

 Any COVID-19 testing intervention can only have an impact if it results in a behavioural change. Moreover, testing is part of a package that could include the promotion of support for those asked to isolate.

What went well?  Over the course of the pilot, 22,133 tests were completed, representing roughly one third of the target population, of which 850 positive cases identified, giving an overall positivity rate of 3.8%  4,733 people registered as asymptomatic within the booking system, of which 593 were positive (12.5%)  15,576 were registered as asymptomatic, of which 228 were positive (1.5%)  The remaining 1,824 were home test kits which resulted in 29 positive cases (1.6%)

What could be improved?  Community testing should be agile and targeted at those communities where it can have the greatest impact.

Conclusions: There is a need to retain a focus on improving equity and local access to testing. Targeted community testing, when combined with other measures, may help reduce community transmission by identifying and isolating positive cases that would otherwise be missed.

Recommendations: 1. Identify geographic areas where there is a concern around levels of community transmission, and then deploy targeted and rapid testing resources within those communities to enhance symptomatic testing provision and offer asymptomatic testing options. This could include bringing testing capacity to places of work and learning in order to improve accessibility. The

58 Letter Community Testing 24 December 2020 (see appendices)

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identification of communities would be supported by test positivity data and a significant expansion of the waste water testing programme.

2. Consider how to integrate and build on the opportunity of an intense targeted period of testing to wraparound a full public health package within a community. This could include the promotion of support for those asked to isolate.

3. Consider measures to ensure compliance with non-pharmaceutical interventions (NPIs) in vulnerable settings and where there are particular risks of transmission within targeted communities.

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12. CONCLUSIONS

The Whole Area Testing Pilot has been largely successful. A range of evidence supports this, in particular:

 Partners were able to work effectively together to deliver mass testing in Merthyr Tydfil and the lower Cynon Valley with a very short lead in time.

 There was high take up in the communities and schools (49% in Merthyr Tydfil, 56 % in lower Cynon Valley), and home testing (36% in Merthyr Tydfil and 45% in lower Cynon Valley), indicating that the testing was both acceptable and accessible. This compares very favourably to other pilot areas in Liverpool (25-30% in Communities and 11% home) and Scotland (33% in communities).

 The vast majority, 99.6%, of those attending for the LFD test were asymptomatic. This indicates that the community understood the purpose of testing and presented appropriately.

 Identifying areas and groups with high positivity rates. These included areas of greater deprivation, males, younger people aged 20-29 years and those in certain occupations i.e. transport, hair and beauty, hospitality, manufacturing and construction, health and social care, retail and arts and entertainment. These results confirm that the highest risk occupation are those where people have closer contact with people, increasing the risk of transmission.

 Identifying settings with low positivity, in particular schools, where positivity was much lower at 0.37%, providing a high degree of assurance in the control measures in schools.

 The lower testing uptake in groups of the population with higher positivity rates has clearly demonstrated an “Inverse Testing Law”. This is an important observation to inform future testing strategies.

 Case control study enabled further analysis of risks of COVID-19 transmission in this population. The transmission within the household was the most important source infection. Working in the hospitality sector, and visiting the pub were significant risks but at the time of this study were relatively infrequent exposures. Smoking or vaping had a small but significant effect. Working in education, living with someone working in education, having caring responsibilities and visiting a supermarket, restaurant, gym or leisure centre did not appear to increase risk of infection.

 The very conservative analysis using evidence based assumptions, daily reproduction number (Rt) and sensitivity analysis demonstrated that 353 cases, 24 hospitalisations, 5 ICU admissions and 14 deaths were likely to have been prevented as a result of this pilot, in Merthyr Tydfil alone.  Cost effectiveness analysis showed that the pilot was highly likely to be cost effective, with an incremental cost effectiveness ratio of £2,292 per QALY gained. Net monetary benefit for the intervention, which is cost savings plus the value of QALYs gained was £5.8 million compared with the £515,688 cost of the pilot in Merthyr Tydfil.

 The intelligence gained from the pilot will inform future community testing and communication strategies. In concluding this report it is important to consider whether the aims and objectives of the Whole Area Testing pilot were achieved.

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In concluding this report it is important to consider whether the aims and objectives of the Whole Area Testing pilot were achieved.

The aim of the pilot was to:

1. Test whether or not large-scale testing can yield a significant and sustained reduction in community transmission.  1, 135 asymptomatic cases were identified in communities, schools and homes.  Cases, hospitalisations, ICU admissions and deaths were prevented.  The modelling of cases prevented demonstrate the significant and sustained reduction in the weeks following the pilot.  The clouding of impact by the National Lockdown on 20/12/20 is important contextually, but the use of relevant data modelling successfully elucidated the impact of the pilot with LFD testing presented in this report.

2. Make testing accessible to an agreed area(s) entire population and incentivise uptake.  Testing was accessible in communities at different times, in schools and at home for those shielding. Home calls in the lower Cynon Valley increased uptake of home testing for those shielding.  The high testing uptake of the population at 49% Merthyr Tydfil and 56% in lower Cynon Valley, which is double that found in the Liverpool pilot, provides evidence to support this.  One stop shop approach to access to support for self-isolation provided easier access to support.  In respect of incentivising uptake, communications played a role: “do your bit”, led by Local Authorities, trusted sources of information and community leadership. However lower uptake in deprived, younger and males indicates that more work is needed to target these populations and additional income support may be a barrier to uptake.

3. Identify index cases and prevent further transmission through contact-tracing and other measures.  Asymptomatic cases were identified in communities, schools and homes.  Contact tracing was offered at the point of test in the main testing stations, but telephone follow up proved to be better in engaging cases and identifying contacts.  Cases prevented, hospital admissions prevented, ICU admissions prevented and deaths prevented.

4. To protect those at highest risk  The outcomes of the analysis demonstrate that identification and self-isolation of asymptomatic cases can prevent onward transmission, hospitalisation, intensive care admissions and deaths. Those in the population that are at highest risk, are those with severe morbidity requiring hospital admission, ICU stays and often result in death. In demonstrating this it is evident that Whole Area Testing with LFD protects those at highest risk.

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5. To empower the local community to arrest and reduce the community spread to as low as reasonably possible in order to save lives and save livelihoods and businesses.  This was evidenced by (1) the levels of community participation, and (2) the actual impact on transmission clearly highlighted in this report.

6. To identify those who are needlessly self-isolating and empower them to return to usual activities.  There were only 21 individuals who had positive LFD results, and subsequently went on to have negative PCR results. These 21 individuals and their contacts were subsequently released from isolation.  It should be noted that 52% of people with a positive LFD result in Merthyr Tydfil, and 61% in the lower Cynon Valley went on to have a PCR test. As a consequence, there will be a small proportion of people (from the 486 that did not go on to have the PCR test) who would have been likely to be negative and continued to isolate along with their contacts. We estimate that would have been 16 people and their contacts.

7. To assess the impact of testing on behaviour of participant.59  There was no data available to evaluate whether or not this was achieved.

The objectives of the pilot were to:

1. Develop a blueprint for whole town, city, borough or regional testing.  This evaluation report provides detailed information and links on the methods used, standard operating procedures, communication and engagement strategies, lessons learned and recommendations for further roll out. This is effectively a blueprint for whole town, city, borough or regional testing. In addition the interim report14 was published to inform further action along with a series of presentations across TTP teams in Wales to inform planning for Community Testing.

2. Better understand prevalence via asymptomatic surveillance.  The Whole Area Testing pilot identified 763 cases in Merthyr Tydfil and 372 in lower Cynon Valley. With 99.6% of those testing being asymptomatic and 49 % and 56% uptake respectively, and positivity rates of 2.3% and 2.6%. This coupled with the positivity rate of different segments of the population, including those under represented but with higher rates of positivity gives a good understanding of prevalence of asymptomatic cases in the population and a much improved understanding compared with symptomatic testing only.  The uptake and results of the Whole Area Testing pilot have provided an important insight into the true prevalence rate in the community. Both symptomatic and asymptomatic cases are probably an underestimate of actual prevalence as they both rely on individuals presenting for testing.

3. Develop an intelligence picture and use asymptomatic testing to limit an agreed area’s acceleration through enhanced restrictions escalation.  The Whole Area Testing pilot has provided important and reliable intelligence to inform further action. It is a key part of the intelligence, along with pilots of LFD testing in other settings and the analysis of the information collected during contact tracing of symptomatic cases from the TTP CRM system to tailor action to further reduce prevalence.

59 Added post implementation and not stated in the SOP and CONOP

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 This will inform the further roll out of community testing to target parts of the population with higher positivity rates to break routes of transmission further in these higher risk groups including geographical areas, occupations and settings.

 With respect to schools testing, the whole school testing can be quite disruptive to the delivery of the curriculum and would be better considered as part of cluster investigation. Targeted testing of contacts of cases would limit disruption, especially if it could be carried out at home, prior to attendance at school with an effective system of validating and reporting of test results.

4. Deploy new technologies in an agile and scalable way.  The Whole Area Testing pilot was successful in demonstrating that the new technology of LFD testing could be deployed in an agile and scalable way. The offer was made across two geographically defined areas, of different population size, with a hub and spoke model to increase accessibility. The lessons learned in the process provide a useful guide to deploy this technology further on smaller and more targeted populations for maximum effect.

Assessment against each of the hypothesis

In returning to the assessment against each of the hypothesis generating in the Liverpool pilot, it can be seen that the potential positive outcomes were all achieved with the exception of reduced morbidity, which was not known. None of the negative outputs were seen, although whether increased risky behaviours following testing and increased mobility were not known.

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13. RECOMMENDATIONS

A number of general recommendations can be made following the learning in this report, as well as specific recommendation in relation to the components of the report.

General recommendations:

The Whole Area Testing pilot in Merthyr Tydfil and the lower Cynon Valley has demonstrated that mass testing using LFD tests is acceptable to the community, effective in preventing cases, hospitalisations and deaths and cost effective as an intervention. The use of mass testing for asymptomatic members of the community should be considered an important and effective part of any COVID-19 Control Plan.

1. The LFD test deployed in the context of high community prevalence of the disease identified infections in asymptomatic persons, with higher positivity rates in some groups and areas than others. As such, future use of this in community testing should be targeted at areas and groups of the population with higher positivity rates. In this pilot this indicates that testing should be targeted in more deprived areas, at men, younger people and occupations with close contact who cannot work from home, for example construction and manufacturing, personal services such as hair and beauty, health and social care and education.

2. Improved support, particularly financial support, is needed to motivate those at the highest risk of having the disease to come forward for testing and comply with self-isolation guidance.

3. It is essential that the implementation of the plan is locally led, in partnership with Local Authorities, health services and the Third Sector.

4. Contact tracing services, in this case the Local Authority led Test Trace Protect service, should be fully integrated into the testing to ensure prompt follow up of cases for isolation and support and contact tracing to ensure compliance and break routes of transmission.

5. Good communication with community members is needed to underpin the roll out and secure good engagement and uptake.

6. It is recommended that information is collected and analysed to inform action in terms of communication, targeted messaged to higher risk groups, developing guidance to prevent transmission as well as monitoring and enforcement. Analysis of uptake rates and positivity rates by geographical area, deprivation, occupation, age and gender provides useful information to inform more targeted community testing and action.

7. Mass testing offers a valuable opportunity to include further research to inform action. The case control study implemented in this pilot is recommended for future roll out to inform action, identify new routes of transmission and comparison risk factors.

8. The use of a hub and spoke model for the location of testing stations is important to allow access to all areas of the community and the inclusion of secondary schools is important.

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Specific recommendations:

Governance recommendations:

The governance and reporting arrangements were felt to work well during the pilot.

9. In establishing Whole Area Testing, it is recommended that a Senior Responsible Officer is appointed to lead and that senior leaders are identified in each partner organisation, including Welsh Government, to form a Steering Group. These leaders should be able to make decisions and allocate resources on behalf of their respective organisations. In addition specialist communication staff should be in place to support. 10. Regular meetings, daily during critical periods, should be maintained to ensure rapid decision making and good communication. 11. Time should be given to properly define the aims and objectives and plan all aspects of delivery.

Planning recommendations:

12. Securing a planning resource and adopting a project management approach to such a project (including lessons learned) is key. 13. Ensure that the planning focus is on the development of an end-to end-pathway, from the point of accessing the testing, all the way through to results received, contact tracing and self- isolation support where required. 14. A good communications and engagement plan underpinning this work is critical to ensure good community awareness and attendance. 15. Ensure a focus on project evaluation at the beginning of the project. This will help secure the right resource and agreed approach as to how the project results will be captured, evaluated and shared. 16. Depending on the context and type of LFD testing service being established, some of the lessons learned above may provide useful recommendations for consideration in setting up a similar service elsewhere.

Implementation recommendations:

17. Implementation of the pilot was the most challenging and labour intensive part of the whole process as might be expected. Good leadership, excellent team work and positive partnering with the Military made this a successfully implemented pilot, set against the backdrop of tight timescales and being new to Wales in nature. 18. It is recommended that in terms of the implementation of similar projects, the Lessons Learned Log is considered, as this provides a range of learning and experience across a wide range of areas experienced during the pilot.

Logistics recommendations:

A robust logistical plan is essential to a smooth operation of a complex programme

19. Provide home testing kits for those that test positive (7 day supply).

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20. Consider at an early stage if Military support is required, and request for a Military Advisory Team (MAT) initially, that can inform whether additional Military support is required either for planning or delivery purposes. 21. Protect - The re-introduction of borough wide or regional resilience planning to strengthen the connection between co-ordinated volunteering and the redeployment of staff across sectors in an emergency situation would be welcomed.

Schools based testing recommendations:

The pilot in schools demonstrated that whole school testing was possible and successful. The following recommendations are made to assist further roll out in Wales:

22. Whole school testing requires considerable resources to facilitate the process. Sufficient time to plan the introduction of whole school testing should be allowed to effectively introduce the testing. 23. Co-ordination from the Local Education Authority is essential to facilitate good communication, the logistics and equipment needed, and to quickly respond to any issues arising. 24. The School Leadership Team should have the flexibility to allow each school to determine the most effective way to deliver the programme in their environment. If all teams are trained, they can take ownership of the programme using generic operational guidance in support. 25. Effective communication with staff, pupils and parents or carers is essential to ensure trust in the programme and high uptake. 26. Messaging to schools should be streamlined, as multiple sources can be confusing. Clear guidance is needed from Welsh Government, allowing scope for bespoke operational arrangements that can be tailored to reflect the local needs of each school community. This should include: a generic pack for schools, with practical examples such as animated videos showing the test in process, etc. Training materials already in circulation within the UK (e.g. Universities) should be assessed by the Welsh Government, and if suitable adapted for use within schools in Wales, e.g. Welsh language. 27. Effective, accessible IT systems should be available to support the testing process and equipment such as bar code readers should be provided. 28. Clarity on flow of data for General Data Protection Regulation (GDPR) purposes would be beneficial. 29. Whole school testing is very disruptive to teaching and normal delivery of the curriculum. If introduced, it would be helpful to limit it to the start of the school e.g. start of term or immediately following lockdown when schools are closed. 30. The LFD test is quick and effective in identifying asymptomatic cases. The use of this test for contacts of cases has great potential to limit the number of children self-isolating and missing school. If such contacts opt out of testing, self-isolation for 10 days after the last contact must be maintained, as well as for any days that the test is not available e.g. weekends and holidays. 31. In using a more selected testing process e.g. for staff and pupil contacts of cases, routinely in schools, it should be noted that there are some limiting practical factors in this approach. In particular, the testing would need to commence at the start of the school day, pupils undergoing the test would need to be isolated until the results are known. This has the potential to create a bottleneck at the start of the school day. In addition there is limited space to test large numbers of pupils, without disrupting other school activities e.g. dining

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halls. This could only be undertaken for small numbers of contacts and not whole year groups. Guidance may need to be amended to provide greater clarity to identify true contacts rather than class, year group or travel bubbles. Contingency arrangements would need to be put in place to safely isolate any positive cases until parents could collect them or safe transport is arranged. This will cause particular problems for schools with a large catchment area reliant on school transport, if parents or carers cannot leave work at short notice or do not have access to a car. 32. Selective use of LFD testing could be extended to all staff to maintain numbers at work, including agency and peripatetic staff, interview candidates and contractors entering the school environment.

Resources recommendations:

33. In order to accurately record resources used it is recommended that finance colleagues are engaged in the early planning and implementation including staff rotas. 34. Although it was possible to repurpose some existing staff roles, for example leisure staff while leisure centres were closed, additional staff were employed to support the pilot and this “additionality” needs funding commitment. 35. The value of additional calls to increase engagement for home testing should be considered as part of any further roll out, having regard to positivity rates in this population.

Analysis of testing uptake and outcomes recommendations:

36. Additional support to low income households to isolate is imperative for greater uptake and compliance. 37. Targeting testing of low uptake occupations with higher positivity rates, including tailored financial incentives should be considered to increase uptake in these groups that have the potential to transmit COVID-19 to larger client base.

Estimated cases, hospitalisations and deaths prevented in Merthyr Tydfil recommendations:

38. Further analysis of the costs avoided by the mass testing, in terms of cost per hospitalisations or ICU admission, relative to the cost of the mass testing exercise will provide further insights into the benefits of LFD mass testing from a health economics perspective.

Economic Evaluation of Merthyr Tydfil Mass Testing Recommendations:

39. It will be useful to compare with economic evaluations of other mass testing pilots such as in Liverpool and other parts of the world. 40. Further analysis could look at the threshold of community prevalence at which mass testing becomes cost-effective.

Waste water testing recommendations:

41. Monitoring of SARS-CoV-2 in the wastewater network provides additional independent and useful information regarding the presence of the virus in the community, which is independent of whole area testing.

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42. Timely planning meeting(s) with appropriate representation from all team partners (not only those primarily involved in wastewater monitoring), reasonably in advance of start of whole area testing, are essential to focus on sampling site identification – taking into account factors such as network configuration, relative ease of access (manholes, CSOs, pumping stations, wastewater treatment works, etc.), special sites (e.g. hospitals, prisons, large businesses/schools/institutions, etc.). 43. Number of sampling sites, sampling frequency and types of sample (grab/composite) need to be calibrated and ensured suitable for area/population. 44. Maintain co-ordination and communication between all team members before, during and after the whole area testing window. 45. Ensure dedicated wastewater monitoring operations team pipeline from sampling through sample processing and analysis to allow results to be obtained and shared in as close to real time as possible; i.e. initial results within 4-5 days of sampling. 46. Confirmed results should be used for higher level analysis, e.g. contextualised and correlated wherever possible with COVID-19 testing and other appropriate public health metrics for the area/population undergoing testing. 47. Continued development of methodologies for wastewater sampling, and processing and analysis of samples suitable for the range of communities across Wales; i.e. urban (large, high- density populations, excellent wastewater network connectivity), peri-urban (medium-sized, variable density populations, good wastewater network connectivity) and rural (relatively small, low density populations, variable or poor wastewater network connectivity) communities.

Communication and engagement recommendations:

48. Establish a good working relationship with partners early on in the process and meet regularly. Communication teams should be involved in the testing planning process from the earliest opportunity so they can understand the testing process, the operational delivery of testing, provide communications advice and limitations, allowing sufficient time to create all content and its delivery, as well as receiving sign off by partners. 49. Clearly define the testing area before announcing and aim to place this within a clearly defined area, which does not cause confusion or cut through communities. 50. Where a testing area is defined across Local Authority boundaries, it should be approached as one event, whether they occur at the same time or one at a later date. This will allow a whole area approach to testing and not viewed as separate events. 51. Local communication teams know their communities the best and should be confident to challenge decisions made by others. 52. Use of local influencers to instil trust and confidence in the process. Also, use these individuals to highlight the consequences of transmission of the virus. 53. To be able to deliver a comprehensive communication and engagement strategy, sufficient leading time and the relevant resources are needed. 54. Have a point of contact at each location so that you can provide regular updates to the public. 55. Be open and transparent in relation to the number of tests undertaken and the results. 56. Engaging with businesses is important, communicating the need for staff to get tested to ensure the safety of their colleagues and customers, but also the benefits to business continuity and ensuring a large number of staff do not need to self-isolate or risk becoming infected.

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57. The need for agreed messages to resolve any operational queries that are received, such as when an individual doesn’t receive their test results, as well as for frequently asked questions.

Case control study recommendations:

This proved a successful addition to the Whole Area Testing pilot. The results of this study have been used to inform the Community Testing Strategy in Cwm Taf Morgannwg.

58. Whole Area Testing is used as an opportunity to carry out studies to answer specific questions relating to the epidemiology of COVID-19. 59. The results of the case control study are used to inform interventions to limit transmission of COVID-19 including communication with the public, testing strategies, advice to businesses and enforcement 60. The study is published in a peer reviewed journal.

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14. CONTRIBUTORS

Our gratitude is expressed to all those people who contributed to the mass testing pilot, and evaluation including, our communities, Local Authorities, Schools, Health Board, Welsh Government, Welsh Ambulance Service Trust, Police, Third Sector, Military, and Public Health Wales.

Whole Area Testing Evaluation Group Members:

Angela Jones, Chair of the Whole Area Testing Evaluation Group, Deputy Director of Public Health, CTMUHB Adrian Davies, Policy Lead for Community Testing, Welsh Government Alun Teagle, Learning Department Support Team, MTCBC Alyn Owen, Interim Deputy Chief Executive, MTCBC Andrea Richards, Service Director for 21st Century School RCTCBC Andrew Jones, Head of Finance, CTMUHB Behrooz Behbod, Consultant Epidemiologist, Welsh Government Brendan Collins, Head of Health Economics, Welsh Government Ceri Dinham, Head of Corporate Communications, Consultation and Engagement, MTCBC Chris Roberts, Head of Behavioural Science Welsh Government (Health Covid19) Christian Hanagan, Service Director, Democratic Services and Communications, RCTCBC Daniel Thomas, Consultant Epidemiologist, PHW Elaine Tanner, Directorate Manager COVID-19 Testing, CTMUHB Helen Griffiths, Learning Department Support Team, MTCBC James Whitehurst, Cabinet, Public Relations & Digital Communications Officer, RCTCBC Professor Kelechi Nnoaham (Professor), Executive Director of Public Health, CTMUHB Lisa Gorringe, Business Manager, Catering Services, RCTCBC Lisa Jones, Personal Assistant, PHW Louise Davies, Service Director for Public Protection, RCTCBC Margaret Munkley, Senior Public Health Practitioner, PHW Mark Drakesmith, Epidemiological Data Scientist, PHW Major Peter Harrison, Joint Military Command (Wales) Paul Griffiths, Service Director, Finance and Improvement Services, RCTCBC Rachel Rowlands, Chief Executive Officer, Age Connects Morgannwg Rachel Thomas, Finance Manager, CTMUHB Dr Richard Kyle, Deputy Head of Research and Evaluation, PHW Dr Robin Howe, Professional Lead Consultant, Microbiology, PHW Rod Francis, Headteacher, Cyfarthfa High School, Merthyr Tydfil Ruth Treharne, Senior Planner, CTM TTP Rutuja Kulkarni-johnston, Consultant in Public Health, PHW Sarah Hopkins, Headteacher, Bishop Hedley RC School, Merthyr Tydfil Sue Walker, Chief Education Officer, MTCBC

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15. APPENDICES

The appendices identified within the footnotes of this report, are available on this website.

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