THIS Institute

Ethical framework for asymptomatic
COVID-19 testing

Students in higher education institutions

This framework is based on a consultation, ethical & legal analysis, and expert discussion.
Over 200 university students and staff took part in the consultation exercise.

Design and operation of the programme

Assess if a testing programme is the right choice and whether you can deliver all aspects of it. Make sure public and legal duties will be met

Recommendations

Start by making an assessment of whether a programme is the right choice for the HEI, taking account of the available evidence, current pandemic conditions, and available resources and capabilities.Ensure that all other infection control measures are in place both prior to making a decision about introducing a testing programme and subsequent to the decision (whether or not it is to proceed). A testing programme should be seen as one element in a multi-modal strategy.Recognise that a testing programme requires a whole-system approach that is designed end-to-end. Testing on its own is not enough; there must also be confidence that the key control measure (isolation of confirmed cases and their close contacts) can be achieved. A HEI should therefore sign up in full to delivering on all of the components necessary for the programme.Set up a governance structure capable of dealing with all aspects of the programme, including clear decision-making, operational oversight, quality assurance, communication, and facilities for consultation and ethical advice.Plan for a range of scenarios and ensure that contingencies are in place.

How might these recommendations be put into practice?

Some hypothetical examples:

  • One HEI identifies all the components that need to be in place for an asymptomatic testing programme for its students. Having satisfied itself that it can deliver on all of these, it decides to proceed. It establishes a governance structure for the programme, identifying key responsibilities and accountabilities in the programme team and a clear decision-making structure. It decides that major decisions should be made by its COVID-19 ‘gold’ committee, alongside other important decisions for managing the impact of the pandemic. Recognising that running an asymptomatic testing programme is very different from the University’s usual operations, it sets up a committee with broad membership which liaises closely with an operational management team.

  • A different HEI, having reviewed the resources required to deliver all elements of a testing programme effectively, determines that it lacks the financial and logistical capabilities to run a sufficiently quality-assured, effective programme. It therefore decides not to proceed.

  • A HEI running a testing programme models a number of scenarios, including situations where testing is conducted routinely during a period of stability, and situations where there is a current outbreak that needs to be managed. It puts plans in place to cope with these, including, for example, scenarios where large-scale staff absences may mean that it is difficult to support isolation, including appropriate meal provision.

Goals of the testing programme

Identify the programme goals, explain why they were chosen, tell students about them, and keep them under review.

Recommendations

Ensure that the goals of the programme are well-defined and have a clear rationale based on disrupting viral transmission through early control measures. The goals should be clearly explained to the student population and other stakeholders. If there are multiple programme goals, they should be acknowledged explicitly.Goals should be realistically attainable, based on current understanding of the epidemiology of COVID-19, the properties of the selected testing regime, and the available resources and measures for managing risk.Specify criteria to judge the effectiveness of the programme in reaching its goals.Keep the programme goals under active review, mindful that they may evolve over time. Goal drift (uses of the programme for purposes not specified) should be avoided.

How might these recommendations be put into practice?

Some hypothetical examples:

  • A HEI identifies the goals of its testing programme. It distinguishes between primary goals (reducing viral transmission through identification and isolation of cases and their contacts) and secondary goals (providing reassurance for students and staff). It explains the rationale and goals of the programme to its stakeholders, emphasising potential benefits it hopes to achieve for students (e.g. reduced risk of contracting the virus, more normality of educational experience, and psychological reassurance), and for those in the wider community (reduced general transmission of the virus). It also acknowledges the current scientific and uncertainties associated with demonstrating whether the programme can deliver on these.

  • A HEI specifies that it will judge the effectiveness of the programme in achieving its goals, using criteria relating to: participation rates, positivity rates (percentage of people tested who are positive), outbreaks, cost-effectiveness, and student satisfaction (measured by surveys). It acknowledges influences outside its own scope of control, such as community prevalence. It monitors effectiveness over time.

  • A HEI keeps the goals of the programme under active review as conditions, technology, policy, guidance, and scientific understanding evolve. The HEI clearly signals any changes to all stakeholders.

Properties of the test(s) selected for the programme

Assess the available testing options, considering current evidence and guidance. Acknowledge uncertainty and take action to address risks associated with the chosen test.

Recommendations

Be alert to the properties of test selected for the programme and the implications of these. Test properties, such as sensitivity and specificity, may vary considerably depending on the test used and the setting (including whether or not swabbing is self-administered).Ensure that the methods of obtaining the sample (e.g. swabbing) satisfy criteria of tolerability and acceptability (e.g. should not induce excessive discomfort, pain, or anxiety).Consider the probabilities of false negative and false positive test results associated with the chosen testing regime, and identify and mitigate the possible associated risks and harms. Acknowledge the implications of false negatives and false positives in communications about the programme.Emphasise prominently and consistently the importance of continuing to observe guidance on masking, social distancing, hygiene and ventilation in the event of negative tests.Clearly communicate what should happen in response to a positive test, including any opportunity for confirmatory testing.Be alert and responsive to changes in evidence surrounding testing technologies, and be aware of current government guidance.Be mindful of relevant legal and regulatory requirements relevant to testing. Amongst other things, HEIs should consider the current authorisation and certification of the devices being used for testing, and any requirements for laboratories being used (whether in-house or under contract) to be certified.

How might these recommendations be put into practice?

Some hypothetical examples:

  • A HEI makes a full assessment of the available testing options. It considers validity and reliability, convenience and speed of administration and test result, tolerability of the test for students, costs, logistical burden and test certification.

  • One HEI, having reviewed the latest government advice and other sources, selects lateral flow testing (LFT) as its testing approach. However, it recognises the limitations of the currently available form of the technology, including the risk that its poor sensitivity could generate high false negative rates. Accordingly, the HEI emphasises in all communications that, for the present, the main goal of the programme is to detect positive cases in asymptomatic individuals. It stresses that the programme cannot provide evidence of non-infection, and that negative results should not be used to support relaxation of compliance with social distancing, face coverings, or hygiene rules.

  • A different HEI also conducts a full assessment of the available testing options. It decides to use PCR testing because of its superior sensitivity, but it also recognises some of the downsides (e.g. longer time to test results). It repurposes some of its own lab capacity to provide the testing facility but takes care to ensure compliance with any regulatory or certification requirements that may apply.

  • A HEI discovers that an unintended consequence of the programme is that those who test negative may engage in more risk-taking behaviour because they believe themselves to be free of infection. In response, it explicitly communicates that a negative test result means a student “has tested negative, but could still be infected with the virus”. It informs students that the asymptomatic testing programme is “one tool in a multi-component risk reduction strategy” and re-emphasises the importance of complying with other measures designed to minimise transmission.

  • A HEI notes that in the event of a false positive, the student would be erroneously required to isolate, as would their close and household contacts (who may not be part of the programme). To mitigate this risk, it decides to offer swift confirmatory testing to anyone who tests positive.

Enabling isolation

Provide suitable support -practical, psychological, social and educational - for students who test positive.

Recommendations

Ensure that adequate support is in place for isolation after a positive test, both at individual and household level. Programme effectiveness in breaking chains of transmission depends on individuals (and their households) isolating after a positive test. Students in HEI accommodation are likely to require the support of their institutions to isolate for practical purposes (e.g. food, laundry etc), general health (e.g. fresh air and basic exercise) and for reasons of mental health (e.g. anxiety, loneliness).Be clear in communication about both about the requirement for isolation and the available support. A dialogue should take place to ensure that those isolating feel heard, and the experiences should be used to guide the refinement of support systems.

How might these recommendations be put into practice?

Some hypothetical examples:

  • A HEI identifies, by listening to students, the challenges associated with asking people to isolate for the specified period and takes them seriously. It identifies and organises the support – practical, psychological, social and educational – required to isolate effectively. It considers cohorting strategies to enable students to move safely outside their own bedroom in a controlled way.

  • A HEI publishes a clear statement outlining polices regarding students who may be educationally disadvantaged as a result of isolating. For example, students who are unable to carry out experimental work are reassured that reasonable adjustments will be made, so that as far as is possible isolating will not result in academic detriment.

  • A HEI communicates clearly with its students about what to do if they receive a positive result, or are a close contact of someone with a positive result, what support is available if they must isolate and how they can access it. Its communication acknowledges concerns and anxiety around having to isolate.

Choices regarding participation in testing programmes

Generally, favour the least intrusive approach to individual choice about participation.

Recommendations

Make a reasoned decision about individual choice regarding participation. Generally favour the least intrusive approach possible proportionate to achieving the goals of the programme and bearing in mind risks, benefits, current levels of scientific certainty and pandemic conditions. Any decision to seek to increase the degree of compulsion should be considered very carefully and should be accompanied by consultation with stakeholders, with the justification openly communicated.Consider the use of any incentives carefully. If used, they should be small and presented as tokens of appreciation rather than stimulation to take part.In general, avoid penalties (or measures that have the appearance of penalties), because they have the potential to impact on trust, undermine solidarity, cause resentment, or lead to a burden of complaints to be managed.Policies on choices about programme participation should be broadly consistent within a HEI and ideally across the HEI sector, though local differences or adaptations may sometimes be necessary.

How might these recommendations be put into practice?

Some hypothetical examples:

  • A HEI offers individual students the choice whether to participate in the testing programme or not, supported by clear communication surrounding the potential benefits of the programme (including the shared benefits of health protection and community solidarity). Entire accommodation blocks as a whole are not permitted to opt out.

  • A HEI, following consultation, concludes that offering small incentives (such as a free coffee for taking part) to encourage participation would be acceptable, because students appreciate their efforts being recognised. It monitors for any unintended consequences, such as the perception that offering either excessively trivial or unduly large rewards could undermine a programme built on community spirit.

  • A HEI considers whether it would be acceptable to restrict access to face-to-face teaching for students who decline to participate in the programme, following complaints from some students about having to share space with untested colleagues. Following consultation, it concludes that it could be seen as punitive and could damage support for the programme overall. It decides to reiterate the principle that participation in testing is voluntary at an individual level, but makes it clear that it strongly encourages students who attend face-to-face teaching to participate (unless medically exempt) for the safety of others. It commits to keeping the policy under review, particularly if evidence emerges that untested students are associated with higher rates of infection.

  • An advocacy group lobbies the HEI to make asymptomatic testing programme mandatory for students residing in HEI accommodation because of the cross-infection risks for local townspeople. The HEI explains that it will consider carefully the concerns, alongside other practical and ethical considerations. As uptake in the programme is high even with voluntary participation, it decides that it cannot justify making participation mandatory, since it concludes that the potential additional benefit of changing the policy is not proportionate to the risk at the time.