LONDON – “Liverpool can beat TB” proclaimed a 1959 public health campaign urging the whole of England’s third-largest city to get X-rayed to screen for tuberculosis.

The same attitude is being applied to the coronavirus, as Liverpool attempts to quash its outbreak by swabbing its entire population.

“My message to people is: Do it for yourself, do it for your family, do it for your community, do it for your workplace, do it for the NHS and hospitals in the city,” said Liverpool Mayor Joe Anderson, who lost his brother to the virus last month, before the pilot program began.

After three weeks of screening, British politicians say the campaign is a success. Anderson said nearly 1,000 people who hadn’t known they were infected had tested positive and are “self-isolating and not spreading the virus.” Prime Minister Boris Johnson said mass testing in Liverpool contributed to a “very substantial” fall in infections and was a “success story we want other parts of the country to replicate.”

When England comes out of lockdown next week, the “tier 3” cities – including Manchester, Leeds, Newcastle, Birmingham and Bristol – will also be offered a “six-week testing surge.”

At a Thursday news conference, Johnson was asked how he plans to deliver mass testing to the 40 percent of the population that will be eligible as of Dec. 2.


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“I don’t want to oversell how easy it is to do this,” he said, adding that takeup would be voluntary but that the military will help with logistics, as it did in Liverpool. The rollout is part of the government’s “Operation Moonshot,” swabbing 10 million people a day at a cost of more than $130 billion.

But some public health officials question the effectiveness and the expense of a mass-testing strategy. Angela Raffle, an honorary senior lecturer at the University of Bristol, told a recent media briefing the Moonshot plans were the “most unethical proposals for use of public funds or screening that I’d ever seen.”

Britain is among a handful of places around the world to try widespread coronavirus testing. Slovakia recently attempted to test its entire adult population, China claims to have tested the 11 million residents of Wuhan, and Iceland also carried out large-scale testing.

In Liverpool, a city of 500,000, about 160,000 people, or a third of the population, have participated in mass testing since it began in early November. An additional 25,000 from neighboring areas were also tested. As of Thursday, 970 people who unknowingly had the virus had tested positive.

Residents are first offered a rapid turnaround “lateral flow” test. Anderson, the mayor, said he went to a local tennis center, got swabbed in his nose and his throat, and within the hour learned he had tested negative. If a sample comes back positive, residents are offered a polymerase chain reaction (PCR) test, which is more precise.


Health Secretary Matt Hancock has praised the mass testing, saying “asymptomatic transmission is the single biggest challenge of this disease.” In the Liverpool region, he said, cases had declined by “two thirds from where we started,” which was “far more than I would have hoped for.”

As of Nov. 3, the weekly rate of covid-19 cases in Liverpool was 300 cases per 100,000 residents. As of Nov. 21, the rate was 158 per 100,000.

But it’s difficult to disentangle the impact of the testing and the impact of government restrictions. Liverpool in mid-October became the first city in England to be placed into “tier 3,” with the highest level of restrictions. Mass testing began on Nov. 6 – a day after a national lockdown brought even more restrictions into effect.

The number of cases across England has since fallen, suggesting the lockdown may be working.

Other public health experts have voiced skepticism about whether testing over a period of several weeks offers much benefit, since the tests present only a snapshot of whether individuals were infected on the day they were swabbed.

For mass testing to work, Raffle said, “you would have to do it on literally everybody every few days.”


Liverpool has the more modest – though still ambitious – goal of encouraging everyone to take two tests, about a week apart, during the pilot. Daily testing will also soon be offered, but only to the contacts of those who test positive, in lieu of an otherwise mandatory two-week quarantine.

Daily testing like that underway in Liverpool could help “end automatic isolation” of close contacts, Johnson told Parliament this week – via video link, because he was self-quarantining after contact with a lawmaker who tested positive. Johnson was playing by the rules, though he is unlikely to be infected. He had the virus in the spring and tested negative after his recent exposure.

“The system is untried and there are, of course, many unknowns, but if it works, we should be able to offer those who test negative the prospect of fewer restrictions, for example, meeting up in certain places with others who also tested negative,” Johnson said.

Sally Sheard, a health policy expert at the University of Liverpool, said that ideally, mass testing could allow a kind of short-term passport for some activities. It may also help inform officials on how to roll out mass vaccinations when the time comes. Where should testing centers be? Is it helpful to put small pop-up sites near shopping centers or send out vans to suburban communities? What incentives work?

Anderson, the mayor, said mass testing isn’t a “panacea” but an “opportunity” to save lives without severe restrictions. He said testing could also help with mental health. “When you get a test and it’s negative, you do get a bit of a lift: ‘Oh, that’s nice to know,’ ” he said.

Critics of blanket testing, however, point out that the rapid turnaround tests being used in Liverpool can miss up to half of those with the virus.


Writing in the BMJ, Mike Gill, a former regional director of Public Health England, and Muir Gray, a visiting professor at Oxford, argued for an “immediate pause” of the Liverpool pilot and a reconsideration of a national “Moonshot” effort.

“Spending the equivalent of 77% of the NHS annual revenue budget on an unevaluated underdesigned national programme leading to a regressive, insufficiently supported intervention – in many cases for the wrong people – cannot be defended,” they wrote.

In some of Liverpool’s poorest communities, only 4 percent of the population has participated in the testing, according to an analysis by BBC Newsnight. Dan Carden, a member of Parliament from the area, suggested to the broadcaster that people who can’t afford to take time off work to self-quarantine may not want to know if they have the virus. Although the government offers grants to people who would lose wages by staying home, a large portion of applications are rejected.

City officials say that uptake has been highest in affluent areas and that they are working to increase turnout in more deprived areas, particularly in the north of the city. They have experimented with door knocking, mobile testing units, and sending home-testing kits in the mail.

In other words, they are doing much of what public health officials did during the 1959 tuberculosis campaign.