TESTING, TESTING, TESTING…… is the mantra repeated across multiple public and private communications, and described by the PM as the key to solving the coronavirus problem.
Specialists in occupational medicine and OH teams are involved in this emotive debate, whether as part of assessment and advice on issues including infection control, return to work, facilitating retention of key workers (including the supply chain) and providing support to employers and HR in relation to evolving national guidance, or for personal reasons.
NHS Occupational physicians may be involved in the planning, design and delivery of NHS staff testing facilities, whilst those working in the private sector may be under pressure from their clients to deliver testing programmes for staff, particularly those considered by their employer to be key workers. The issue of testing has been under close scrutiny at the FOM, many members have asked about the Faculty’s position. The focus of this information sheet is to offer some background to assist occupational physicians and OH teams in facing this challenge.
Validated diagnostic testing for COVID-19
COVID-19 is a new pathogen for which there is as yet a limited evidence base. Swab testing for viral antigen has been developed and Public Health England has issued guidance in relation to the validated testing which PHE and its associated laboratories, working with NHS England and NHS Improvement can now provide. Testing capacity is limited and only available at present to those who meet the defined criteria for diagnostic testing.
See: COVID-19: Investigation and initial clinical management of possible cases  – 30 March 2020
Patients have been the priority for testing but during the past week PHE approved tests have been offered on a gradual basis to groups of NHS staff. NHSE has prioritised those working in critical care, emergency departments, ambulance services and high priority groups identified by the NHS locally. This programme includes testing suspected coronavirus sufferers in a quarantined household which is shared with a key NHS staff member. This testing programme, for which specific laboratory capacity has been allocated nationally, is designed to support retention of NHS staff enabling those who do not have the virus to remain at work.
See: COVID-19: Testing to support retention of NHS staff  – 29 March 2020
The national COVID-19 plan is to increase testing for defined groups of key workers as validated testing capacity increases. This has already started in some parts of the UK, most notably for police and fire services and their families.
Testing for antibodies to COVID-19, i.e. looking for evidence of an immune response to the virus is not yet available from PHE laboratories. Whilst the presence of antibodies in a serum test may suggest improved immunity the evidence base does not yet allow this to be definitely confirmed, nor to predict how long such immunity may last.
Further background on validation of laboratory tests in the UK, and on testing for COVID-19 is to be found at:
- UK Standards for Microbiology Investigations: Evaluations, validations and verifications of diagnostic tests , PHE and NHS 2017
- Royal College of Pathologists Briefing: Testing for COVID-19 
Public Health England, as publicised in ministerial briefings, is working with private partners from industry to deliver an increased capacity for validated testing, i.e. from laboratories whose testing performance matches that required by PHE, including the accuracy of testing.
Other non- PHE validated testing facilities
Occupational physicians working for international companies may be involved with testing programmes in other countries, which may have their own standards for laboratory accreditation and validation of tests. This information sheet is confined to testing for COVID-19 in the UK, but the principles which underly workplace based testing should be applied in all circumstances.
Many commercial companies are offering tests for COVID-19 in the UK, including antibody based tests. The current view of PHE is that use of such tests is not advised because there is little information about their accuracy, nor at present sufficient evidence of how a patient’s antibody response develops or changes during COVID-19 infection to know whether a positive or negative (antibody) result is reliable. PHE guidance also indicates that there is no published evidence about the suitability of the tests currently available for use in community pharmacies or at home for diagnosing COVID-19 infection in a community setting.
See: Guidance on coronavirus (COVID-19) tests and testing kits  – 02 April 2020
It is also important to recognise that the reliability and validity of all testing results may depend on good practice in taking, storing and transporting samples in careful compliance with specific testing instructions.
Workplace related testing
Testing for COVID-19, in association with work, must be for the benefit of the individual worker and should conform to the same principles as for all other workplace testing/health screening programmes. These are:
- (All primary prevention should have been implemented as far as reasonably practicable)
- Tests must be safe, simple, acceptable and validated
- Testing should be directed at an important health problem
- The condition should be understood
- Further investigation and, where necessary, treatment should be readily available
- (Strong) evidence that screening reduces mortality or morbidity should be available.
In the context of the present situation the first and last requirements may not be practicable because of the paucity of evidence relating to COVID19. It is however important that employers and workers are clearly advised on the limitations and accuracy of testing, and that the implications of a positive or negative result can be clearly explained. The nature of this epidemic is creating much concern, consent to testing should be informed and wherever possible freely given, although the pressure on critical services is creating situations in which such consent may be subject to conflicted interests for both worker and employer.
It is likely that testing regimes may also give rise to certification or passporting practices and potential for fraud or misuse should not be ignored.
Advice on testing and health surveillance, with other information relevant to these issues is contained in the Faculty of Occupational Medicine’s publication:
ETHICS GUIDANCE FOR OCCUPATIONAL HEALTH PRACTICE 8th Edition 2018. This is also available on line as an e-book for members at https://my.fom.ac.uk 
The FOM is grateful for the work of the Faculty Ethics Committee, and the current dialogue and collaboration with colleagues, particularly those working in occupational medicine and the wider OH community, which has made this information sheet possible. It will remain under review.
Dr Anne de Bono
Dr Steve Boorman
Chair, Ethics Committee