Covid-19: Mass population testing is rolled out in LiverpoolBMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m4268 (Published 03 November 2020) Cite this as: BMJ 2020;371:m4268
All rapid responses
A mass COVID screening programme has been rolled out in Liverpool, with further plans announced this week for mass testing of asymptomatic university students across England before they return home for the Christmas holidays.
Mass testing programmes, although often intuitively appealing, can raise complex ethical issues. Public health, focused as it is on protecting and promoting the health of populations, requires a distinctive ethical approach compared with traditional bioethics.[3 4] The importance of establishing a transparent process whereby ethical issues are raised, debated and managed in a way which encourages involvement from different stakeholders has been emphasised, both with regard to public health interventions more generally,[4 5] and specifically in pandemic response. But because COVID-19 is such a new and rapidly-developing situation, not much is known about any concerns people might have about these sorts of testing programmes, and how they might be addressed.
Just as screening programmes should be supported by sound scientific evidence for their effectiveness, so too should they be based upon a compelling ethical framework. We believe that there a pressing need for the development, based on stakeholder engagement and ethical analysis, of a robust ethical framework to guide mass testing for asymptomatic COVID-19, building on work that has already identified ethical considerations relevant to COVID-19 swab testing of NHS workers.  Such a framework would enable systematic and principled decision-making, helping to assure the ethical standing of mass testing programmes for COVID-19. In a pandemic response mired in controversy and challenge, thinking deeply and in an anticipatory way about ethical issues is likely to pay many dividends.
Dr Caitriona Cox and Professor Mary Dixon-Woods,
1. Iacobucci G. Covid-19: Mass population testing is rolled out in Liverpool. Bmj 2020;371:m4268 doi: 10.1136/bmj.m4268[published Online First: Epub Date]|.
2. Coughlan S. Student Covid tests for Christmas holiday from 30 November. Secondary Student Covid tests for Christmas holiday from 30 November 2020. https://www.bbc.co.uk/news/education-54888464.
3. Kass NE. An ethics framework for public health. American journal of public health 2001;91(11):1776-82
4. Marckmann G, Schmidt H, Sofaer N, Strech D. Putting public health ethics into practice: a systematic framework. Frontiers in Public Health 2015;3
5. Childress JF, Faden RR, Gaare RD, et al. Public Health Ethics: Mapping the Terrain. The Journal of Law, Medicine & Ethics 2002;30(2):170-78 doi: 10.1111/j.1748-720X.2002.tb00384.x[published Online First: Epub Date]|.
6. Thompson AK, Faith K, Gibson JL, Upshur RE. Pandemic influenza preparedness: an ethical framework to guide decision-making. BMC Med Ethics 2006;7:E12 doi: 10.1186/1472-6939-7-12[published Online First: Epub Date]|.
7. Institute T. Testing Times: An ethical framework and practical recommendations for COVID-19 testing for NHS workers, 2020.
Competing interests: No competing interests
Last week the BMJ reported the start of a mass screening project in Liverpool . The article suggested this was a pilot study, aimed at studying the feasibility of the government’s ambitious plans for mass population screening throughout England. I welcome Dr Angela Raffle’s timely comments , questioning the rationale behind this and the lack of scrutiny by the UK National Screening Committee. It is particularly worrying to see that despite all the effort involved on obtaining swabs to compare PCR against the new rapid Lateral flow and LAMP tests, there is no mention of testing against the gold standard of viral culture. Yet it appears that on the basis of the tests, asymptomatic children and adults will be sent home from school or work to self-isolate, along with, presumably, all their close contacts.
Parent group #UsforThem had already received copies of letters coming out from secondary schools in Liverpool on the evening of Friday 6th November, informing parents of the study starting in their child’s school starting on Monday 9th. There was no proper information about the purpose of the study or the method of obtaining informed parental consent. One school wrongly stated the there wasn’t time for this and invited parents to opt out in writing. This same school stated in the parent letter, ‘It is important for the health of your child, those of other parents and carers … and the wider Liverpool community that we co-operate 100% with this system of health protection.’ Another school has written to parents congratulating them on their ‘heart-warming responses’ and then listing the number of refusals in each year group and stating ‘I feel really proud of the rallying round of the community here’. In another school letter, parents were asked to ‘please bear with us - we are currently less than 24 hours on from receiving notification of and agreeing to this.’ This same letter referred to ‘nonsensical comments on social media about mass testing’. The school states, ‘We are currently working on reshaping and re-affirming our school values. One of the words I expect to emerge is ‘trust’… I would urge you to trust the school that this is the right thing to do.’
I quote these examples to illustrate a totally inappropriate pressure being brought on parents to give consent. As a group, #UsforThem has written to the director of public health in Liverpool and the director of PHE  asking to see the study protocols, ethical approval and parent information leaflets but have as yet received no satisfactory replies. Our request has now been escalated by the MHRA devices section to NHS Track and Trace.
As a demographic, children have been disproportionately affected by the pandemic management. There is now good evidence of their extremely low likelihood of serious disease  and the small part they play in viral transmission . Whilst we would all welcome rigorous research for the new rapid tests and population studies, these must surely be conducted with appropriate ethics committee approval and a sound methodology. Above all, parents must not be placed under psychological pressure to participate, a clear contravention of agreed ethical standards in the Declaration of Helsinki 1964/2013 .
Finally, may I join Dr Raffle and many others in asking urgently for assurance from the government that the results from Liverpool will be properly analysed and published with full costings, before being rolled out elsewhere.
Dr Rosamond AK Jones, MD, FRCPCH
 Iacobucci G. Covid-19: Mass population testing is rolled out in Liverpool. 03 Nov 2020. https://www.bmj.com/content/371/bmj.m4268
 Raffle AE. Screening the healthy population for covid-19 is of unknown value, but is being introduced nationwide. 09 November 2020. https://blogs.bmj.com/bmj/2020/11/09/screening-the-healthy-population-fo...
 Jones RAK. Letter to PHE regarding testing of children in Liverpool screening pilot. https://www.dropbox.com/s/egb8nrfcn6x9nm2/Letter%20to%20PHE%2C%20MHRA%20...
 Swann OV, Holden KA, Turtle L et al. Clinical characteristics of children and young people admitted to hospital with covid-19 in United Kingdom: prospective multicentre observational cohort study. https://www.bmj.com/content/370/bmj.m3249
 Ismail SA, Saliba V, Lopez Bernal J, Ramsay ME, Ladhani SN. SARS-CoV-2 infection and transmission in educational settings: cross-sectional analysis of clusters and outbreaks in England. https://assets.publishing.service.gov.uk/government/uploads/system/uploa...
 WMA Declaration of Helsinki – ethical principles for medical research involving human subjects. Fortaleza, Brazil. October 2013. https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-pr...
Competing interests: No competing interests