Cases of covid-19 are rising again across the world. This virus is likely to become endemic, even if a vaccine is deployed. The UK pandemic response has evolved through learning, albeit imperfectly, from experiences at home and overseas. [1] The covid-19 pandemic should have pushed virology to centre stage. Instead, practising clinical virologists have been sidelined. 

The opportunity to bring together UK laboratory expertise early in the pandemic was lost as a result of a spurious assumption of lack of capacity, leading to the outsourcing of pillar 2 testing to Lighthouse laboratories. [2] This approach, divorced from the NHS and Public Health England diagnostic expertise, has been dogged by problems in accessing testing, sample receipt and processing, test quality, and data linkage to public health and other NHS structures. All of these would have been minimised if the testing programme had been developed and expanded under the auspices of existing NHS centres of expertise—the same expertise which has led to the development and implementation of tools for diagnosis, monitoring, and public health control of other newly emergent viruses such as HIV, HCV, HEV, SARS, MERS, Zika and Ebola. [3] We also recognise the slow demise of a network of high quality diagnostic services, together with surveillance and epidemiology functions, following the disbanding of the Public Health Laboratory Service (PHLS – the early precursor of Public Health England), the loss of UK high quality diagnostic manufacturing capability, and cost cutting and rationalization. [4] 

The current division between government scientific advice (through SAGE and other committees), and operational efforts (for instance NHS Test and Trace) has further fragmented the response and we note a paucity of clinical virologists on advisory committees. [5] The role of such individuals and other laboratory clinicians is specifically to bridge this gap, using new scientific understanding to advise on issues such as infectivity, surrogates of disease progression, test performance, and infection control. Is it no surprise that the literature is increasingly peppered with discussions about covid-19 PCR performance, and the relevance of low levels of virus —something that clinical virologists have been dealing with since the first introduction of molecular testing in the 1990’s. [6] The role of clinical virologists will be even more important when it comes to monitoring SARS-CoV-2 vaccine responses and assessing the effectiveness of antiviral therapy.  

Because of the lack of engagement by the government and their advisory structure with clinical virologists, 69 clinical virologists, representing most of the consultant level specialty in the UK (and of the Clinical Virology Network) recently wrote to the Chief Medical Officer and Government Chief Scientific Adviser expressing their concerns. [7] The government’s response indicated that SAGE would welcome papers for consideration, especially where there were gaps. We will pursue this suggestion pointing out that rather than gaps, there are gaping holes.

In spite of concerns around the current Test and Trace programme, and the Lighthouse laboratories, a further huge expansion of SARS-CoV-2 testing has been proposed. [8] Firstly, a £5 billion tender for public health microbiology, followed by the even more ambitious £100 billion Moonshot programme, although the rationale for this is unclear, and the technology required may not yet exist. [9,10] Scarcely a week goes by without a media report of a new and better test for SARS-CoV-2 in the pipeline. The collaboration of academia and industry in their development is to be welcomed. However, it is essential that clinical virologists should be involved in the design and clinical setting evaluation of such services, as is standard for all other laboratory and point of care testing. This should include both diagnostic and screening services in all laboratory and non-laboratory settings as the role of testing expands, such as at UK airports, or regular home testing. With winter approaching, it is not clear how the current testing system will take account of the role of influenza and other respiratory viruses. Again, this should be discussed with clinical virologists.  

And to cap it all, Public Health England is due to be replaced by a new health agency—The National Institute for Health Protection. Precisely what is to be achieved by this is unclear. This can only be welcomed if it will result in a better infrastructure, more recurrent resources, and utilisation and expansion of relevant talent. [11]

With global population growth, overcrowding in many low and middle-income countries, cheap air travel and the persistence of wet markets, there will be more emerging infections. Clinical virologists have a crucial role to play in helping to mitigate this risk, but will this lesson be learned?

Jangu Banatvala, School of Medicine and Dentistry, Kings College London. 

Deenan Pillay, Division of Infection and Immunity, University College London. 

Will Irving, School of Life Sciences, University of Nottingham.

Competing interests: Deenan Pillay is a member of Independent SAGE. 

References:

1. BMJ 2020: The UK’s public health response to covid-19. Editorial BMJ 2020;369:m1932
2. https://www.lighthouselabs.org.uk/
3. Mahy BW. History of Emerging Viruses in the Late 20th Century and the Paradigm Observed in an Emerging Prion Disease. Perspectives in Medical Virology 2006; 16: 5-14.
4. PR Carter. Report of the review of NHS pathology services in England. https://www.networks.nhs.uk/nhs-networks/peninsula-pathology-network/documents/CarterReviewPathologyReport.pdf(2008), Accessed 10th September 2020
5. https://www.gov.uk/government/publications/scientific-advisory-group-for-emergencies-sage-coronavirus-covid-19-response-membership/list-of-participants-of-sage-and-related-sub-groups
6. Jefferson T, Spencer E, Brassey J, Heneghan C. Viral cultures for COVID-19 infectivity assessment. Systematic review.  medRxiv  2020.08.04.20167932;  doi: https://doi.org/10.1101/2020.08.04.20167932
7. https://www.clinicalvirology.org/
8. Roderick P, Macfarlane A, Pollock AM. Getting back on track: control of covid-19 outbreaks in the community. BMJ 2020;369:m2484
9. Iacobucci G, Coombes R.  Covid-19: Government plans to spend £100bn on expanding testing to 10 million a day. BMJ 2020; 370 :m3520
10. https://blogs.bmj.com/bmj/2020/09/10/martin-mckee-will-boris-johnsons-moonshot-become-lost-in-space/
11. Banatvala J. COVID-19 testing delays and pathology services in the UK. Lancet 2020; 395: 1831