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 1 | P a g e 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) 2 | P a g e 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. 3 | P a g e 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 4 | P a g e 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 5 | P a g e 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.