Written evidence submitted by The British Infection Association (CLL0079)

The British Infection Association (BIA) is the leading UK professional society for infection specialists, the vast majority of its 1700 members being consultants or registrars in Infectious Diseases, Medical Microbiology and Virology in the NHS.

The BIA submits evidence to the inquiry on behalf of its members. This evidence has been collated from responses to a direct request via email for evidence related to the testing, prior preparedness and treatment domains, and through responses to a survey. We are aware that other organisations such as the Healthcare Infection Society and Infection Prevention Society and making responses in relation to infection prevention and personal protective equipment and have this not commented in these areas.

An overarching theme in the responses we have received relates to centralisation of decision making as regards testing and infection prevention. This made rapid localised decision making difficult as acute Trusts wanted to wait for central guidance which inevitably introduced delay and lost local relevance. This was compounded by poor communication through official channels between NHSE and PHE with local infection services responsible for delivering diagnostics, infection prevention and treatment. Unfortunately the recent “Key actions: infection prevention and control and testing” which appeared Nov 17thwithout discussion with local practitioners and created very significant challenges illustrates to us that this problem persists 9 months into the pandemic response.

https://www.england.nhs.uk/coronavirus/publication/key-actions-infection-prevention-and-control-and-testing/

Key lessons

Professional bodies such as BIA exist to provide advice to and liaison with organisations like PHE and NHSE. Closer working with specialist organisations like BIA could had provided rapid “critical friend” input to decision making and a route to dissemination and professional engagement.

Greater empowerment of local infection services would have targeted interventions to control the pandemic more effectively and potentially had a substantial impact especially on the early course of the pandemic.

 

TESTING

Provision of COVID-19 testing capacity is a major area of concern for our members, who include the microbiologists/virologists across the NHS who has been responsible for building capacity and delivery of NHS testing. In the appendix to this letter we attach findings of a rapid survey we sent to our members in preparation for this submission.

There have been wide ranging supply issues with either swabs, transport media or reagents required for PCR assay.

Pressure to deliver SARS-CoV-2 PCR testing impacted upon the provision of other services by laboratories.

Many laboratories had to use send-away testing and in doing so turnaround time for assays presented a challenge

There was huge variation and confusion across the NHS as regards staff testing. Problems were compounded by Inadequate capacity either at site or at hub laboratories to cope with the high volume of HCW testing, inability to respond to the operational difficulties related to staff sickness/absence, restrictions imposed by PHE on staff testing in early months of pandemic. Logistical challenges of requesting, arranging and reporting staff testing, lack of Occupational Health service capacity, lack of appreciation of importance of staff transmission of the virus despite early data from Italy demonstrating its potential relevance.


Nosocomial transmission of COVID has been an ongoing issue which has received little attention so far in the public domain. Decisions about who to test and when early in the pandemic almost certainly led to a lot of nosocomial infections and HCW infection in secondary care. This was understood locally at many organisations where infections specialist wanted to test all people with pneumonia but instead had to restrict to specific geographic locations and then wait for 'all ICU  patients' to be tested.

Lack of connectivity and data-sharing between pillar 1 and pillar 2 systems meant that tests often had to be repeated when relevant due to lack of a local record.

Key lessons

A broader network of laboratories involved in method assessment and validation would have improved the efficiency of testing expansion.

Empowerment and support of local diagnostic services may have allowed testing capacity to be developed more rapidly, used more efficiently and targeted more precisely to deal with a rapidly changing situation.

Investment into additional testing in NHS laboratories rather than laboratories separate to the NHS would have improved efficiency of testing, reporting and action and resulted in significant legacy benefits for NHS Infection Services.

 

PRIOR PREPAREDNESS
Prior availability of NHS infection expertise and facilities, (diagnostics and therapeutics, was poor as a result of laboratory mergers, centralisation and lack of investment. Infection expertise in the NHS has traditionally been provided by microbiologists . Centralisation of laboratory services has left NHS hospitals without laboratories. At these hospitals many consultant posts have fallen vacant and not been filled. Reduction in the capacity and molecular virological expertise at PHE further compromised national response.

Infectious diseases services in the UK remain centralised in a small number of super specialist centres including the High Consequence Infectious Diseases (HCID) units. This has meant provision of near-patient infection expertise and services have been lacking some regions of the country. This has undermined diagnostic testing, infection control practice and provision of local public health services.

Research has rightly been at the heart of the pandemic response but has highlighted lack of capacity in infection research outside a small number of centres. While contributions have been made from other medical specialties including critical care, respiratory medicine, neurology and acute medicine much of the burden has fallen on the very small number of infection specialists in the UK to lead conduct of trials the UPH studies. There is lack of training and lack of recognition for research time in NHS job plans.

We note this problem is not new or specific to COVID-19. It has hampered and will continue to hamper efforts to meet the challenge of antibiotic resistance for example which can be seen as a slow-moving pandemic. The failure of the NHS to meet antibiotic reduction targets is partly due to lack of near patient infection expertise to guide diagnostic decision making, treatment decisions and infection control practice.

Key lessons

Specialist commissioning needs to take a broader view of what an infectious diseases service looks like considering the service specification which we and the Royal College of Physicians have produced.

A network of specialist infectious diseases sitting beneath / supporting the HCID centres should provide capacity for a more regional / localised  response to emerging infection threats.

Capacity needs to be built in NHS clinical infection research

A local (ICS) level view is needed of provision of infection services to ensure equality of access across the NHS.

 

TREATMENT

The success of the NIHR Urgent Public Health study processes and the set-up of interventional research studies such as RECOVERY was tremendously important in ensuring patients with COVID were given access to well-designed trials rather than given unproven treatments outside trials.

The pace at which we moved from managing patients within HCID centres to managing patients across the whole country meant it was very hard for front line clinicians making treatment decisions to keep up with evidence and ensure their patients had access to the right trials. In this space a group of infection specialists based initially in the HCID centres formed the Clinical Therapeutics Advisory Group (https://www.ctag-support.org.uk). This provided invaluable advice updated very frequently especially during the summer of 2020 in a way that the NICE rapid reviews could not. The approach of NHSE releasing CAS statements around treatments based on press-releases rather than published data (e.g. as happened at different times for remdesivir, steroids, and tocilizumab) underscored the need for a national body to provide practical evidenced based guidance in close to real time.

Key lessons

CTAG provides a model which NHSE should consider for future rapidly emerging threats. It needs to be properly constituted and funded.

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Appendix 1. Brief survey of BIA members regarding COVID-19 testing.

The survey focussed on testing aspects of the pandemic and has so far received 40 responses from at least 29 NHS Trusts, including both DGH and Teaching Hospital sites.

 

Challenges faced in providing a robust testing service by trusts performing in-house PCR testing

In the survey, respondents from Trusts who were performing PCR testing were asked the question “Have you had any difficulty in providing your SARS-CoV-2 assay?” with a series of response options. 16 responses from at least 15 different NHS Trusts were received as detailed below (1 respondent provided no geographical details):

 

Overall 13/16 respondents (81.25%) described facing supply issues with either swabs, transport media or reagents required for PCR assay.

One respondent also complained that the NHSE centralised supply seemed to be delivered to one laboratory in the region only and that this created logistical issues with staff required to collect the kits whereas it would be more efficient to deliver kit to each laboratory directly.

A variety of measures taken to attempt to circumvent these issues were described including:

 

impact on other services provided by laboratories

13/16 respondents from trusts performing PCR testing stated that their provision of SARS-CoV-2 PCR testing had impacted upon the provision of other services by the laboratory. Examples of this impact included:

 

Challenges faced by laboratories performing SARS-CoV-2 PCR assays by send-away to reference or regional hub laboratories

Respondents from 11 different Trusts answered the question “Were any issues faced with send-away PCR when used?”

The majority of respondents stated that turnaround time for assays had presented a challenge. 4 of 11 (36.36%) had experienced issues related to capacity of the send-away laboratory and in free-text comments, one respondent expanded this to mention communication difficulties related to capacity. 2 respondents mentioned the importance of efficient IT communication between laboratories and alignment of systems within and between regions is currently extremely variable and has a significant impact on efficiency and quality of service extending far beyond the specific requirements of COVID-19.

Healthcare worker (HCW) testing

Although only 13 respondents (all from different NHS Trusts) answered questions about HCW testing, enormous variation was identified, both in terms of stage of the pandemic at which it was introduced and criteria for testing:

Comments expanding on the challenges faced included:

Communication with Pillar 2 testing

9 of 12 (75%) of respondents, all from different NHS trusts, stated that they had experienced difficulties obtaining data on SARS-CoV-2 tests performed at other sites which were relevant to their infection control management of the outbreak. Most of the comments related to inability to receive data from pillar 2 test sites either in terms of test being done, results, or their interpretation. This included tests performed on HCWs as well as patients and timely access to such data is clearly critical to efficient infection control management. Lack of connectivity and data-sharing means that these tests often have to be repeated when relevant due to lack of a local record.

Theme 6 – Infrastructure or support that would have been beneficial to response

A free text question was included in the survey asking respondents to state what additional support would have improved their regional networks ability to respond to the diagnostic demands of the pandemic. Responses not covered by the preceding themes are detailed below:

 

Theme 7 – summary of other comments related to testing lessons

 

Appendix 2: other issues raised

Many of those patients discharged from ED or who remained in the community throughout now have long COVID and this is coupled with a perception that they could not access care including from their GP’s.

This is evident in the healthcare workers who became ill themselves.

https://bmjopen.bmj.com/content/10/11/e040216

This survey was undertaken at the start of the epidemic in London where HCW’s could not access testing. HCW’s who were unwell for a prolonged period , felt abandoned at home without adequate support from primary or secondary care. Many have ongoing symptoms of Long COVID and I wonder how much the lack of recognition of the severity of illness contributes to some of the ongoing mental health issues in this Long COVID cohort.

 

Responding to emerging evidence on Anosmia

The limiting of testing to those being admitted who met a case definition focused on respiratory presentation meant that despite evidence from ourselves, the COVID symptom tracker app NERVTAG were slow to include this in the case definition. This undoubtedly resulted in transmission, particularly in healthcare settings.

 

The findings from this survey https://bmjopen.bmj.com/content/10/11/e040216 were raised with the DoH but at that time NERVTAG felt there was no evidence to include anosmia. Or indeed evidence that these people would be infectious with this symptom in the absence of fever or cough. HCW’s continued to come to work ( indeed we actively told them to stay at work) with anosmia whilst not wearing a mask.

The letter from ENT UK on the 22.3.20was raised at the start of April in light of our survey, and the case definition changed on the 18th May.

https://www.entuk.org/anosmia-potential-marker-covid-19-infection-–-update

https://www.gov.uk/government/news/statement-from-the-uk-chief-medical-officers-on-an-update-to-coronavirus-symptoms-18-may-2020

 

Nov 2020