Coronavirus Home-Testing Kit - How Hard Can It Be?

I love citizen science. I think it's a fantastic way of engaging people who don't normally engage with science and also a way of giving people ownership of their information in a way that traditional methods can't always achieve. So when I heard that Kings College London were creating a COVID Symptom Tracking app for people I jumped at the chance to take part. Last week I reported a sore throat. It was most likely due to me not drinking enough while the weather had been particularly hot but it was something out of the ordinary and I felt I should report it just in case. A few days later I was asked to take a COVID-19 test. They noted that,

This does not necessarily mean you have COVID-19 as we are also inviting some people we believe do not have the virus.

I was pretty confident that I fell into this category but have been curious about the Home Testing kits and felt I would take the opportunity to give them a go.

Ordering the Test

The first task was to apply for the test. I was told I needed to use the Essential Workers Test because there wasn't an option for "being part of a study" so I duly did this. I had to give a lot of information "to prevent fraud". What sort of fraud was never explained but apparently it was so great a risk that prevention required my National Insurance Number and some form of credit check (apparently just to verify me details but still).

I received an email from Coronavirus Home Testing confirming my order (though the email began Important Message About COVID-19 which was an interesting way of telling me they'd received my order). The email also gave a set of instructions:

There's three URLs I have to follow there. One to arrange collection of the test, one to register the test and one to watch a video of how to do the test. I watched the video first. It's about 5 minutes long and Dr Khan does a valiant job but my goodness it's a bad video. For one thing, the editor decided that just having the camera directly on the Doctor's face was far too boring, so they went for side views as well, so you got to see him in profile speaking to... who knows? Certainly not the person watching the video. Dr Khan is friendly and tries to be reassuring but he's really not being given the best material. Even when he's going through the kit we're to use he has to explain that some people may not have a particular item. If it's not essential why are they putting it in any kits? Why add variation where none is needed?

Now we get on to taking the samples. He says "it is a bit fiddly, but we'll go through it together". So what do we have to do? We have take our sterile swab out of its packaging and take a sample from our tonsils. He explains,

It is vital you don’t get any unnecessary or additional germs on the swab accidentally by touching your teeth, tongue or gums.

Now, I admit I baulked at this. I have a serious gag reflex. I can't even brush the back of my tongue without wanting to retch and just thinking about getting a swab, however fine, that far to the back of my mouth was making me physically nauseous. Dr Khan notes that "the next part is tricky but super important" and explains we need to wipe the swab over our tonsils 5 times on each side. Given the importance of this step you'd expect the video to show you how Dr Khan did it, or even an illustration of where the tonsils are so that anyone not quite sure are able to see. But no, it's time to switch to the profile shot so we see nothing of use to anyone. 

Next we have to swab the inside of our nose which isn't pleasant but nothing too difficult. Dr Khan emphasises that,

It’s really important to follow these instructions exactly.

The video goes on to explain how to package the sample. You have to put it into a tube containing some undisclosed solution and then put a barcode on this tube lengthways. He notes that,

If your tube has any existing labels on it, place the barcode label over these

Why are they providing tubes with pre-existing labels if they are just getting in the way? Is this someone's way of getting rid of excess stock?

Dr Khan waffles on a bit after this but that's the end of the useful stuff, so now I feel as prepared as I can be.

Waiting For The Test

The next day I get an email from NHS UK, informing me that my test has been dispatched. This is a completely different email from the one confirming my order and while it calls itself the NHS, the address is actually fba-customer-ship-confirm@amazon.co.uk. Yes, that's right. Amazon is masquerading as the NHS. Isn't outsourcing wonderful.

This email gives a similar set of instructions to those given the previous day, but there's no URLs this time.

I can track my package, which is called "1 x Medical Wire: Sigma Virocult Sample Kit". Why they can't just call it COVID Home Testing Kit I don't know. I'm told that the test will arrive between 8am and 4pm. So, of course, it arrives at 6.20pm.

Test Admin

As the confirmation email explained, I have to register my test and book the collection. But because the test arrived late I couldn't book the collection as it has to be done between 8am and 4pm. So I had to wait until the following day. Booking the collection required providing not just the barcode number of the postage return label (not including any #s because why make a step simple when you can make it complicated) but providing personal information as well. I registered the test and this time I got an email from donotreply@dockethub.com. That's the third organisation for those who are counting. 

Then the time came to take the test. But before I could do that I had to register it. So off we go to the computer again, this time to a government website where I had to yet again provide my personal details along with a different barcode to receive a confirmation email from a fourth email account, noreply@test-for-coronavirus.service.gov.uk.

It could be argued that providing all this personal information time and time again is a way of protecting against fraud but I have yet to work out why anyone would be wanting to fraudulently take these tests other than to somehow screw with the data, and I can't see anyone doing that in sufficient numbers to achieve this goal. What feels the more likely explanation is that different organisations have said they 'need' this information for some purpose and the government has said "fine, whatevs". 

Taking the Test

So the time has finally come to take this test. I will admit I wasn't looking forward to it. More accurately I wasn't looking forward to the throat swab. I've been trying not to think about it so as not to accidentally psych myself up in a way that made it harder to do but I'm not going to lie, I was anxious. 

I got the kit out. The first thing to note is there's a lot of pieces - 9 in total. The next thing to note is that the test wasn't the same as the one I watched in the video. There was no extra tube mentioned, the instructions were different, the barcodes for the swab tube were different. The next thing to note is that the test didn't exactly match that one illustrated in the instructions which had the swab and swab tube supplied separately while mine came in one sealed pack.

The kit consists of a flat-pack box which comes with it's own set of construction instructions, a barcode for the box, a set of barcodes for the sample, a swab, a swab tube containing liquid, a plastic bag, another plastic bag with a silver seal, a sheet of absorbent material and the instructions. That's quite a lot of pieces! 

I decided to get the organising part sorted first. I constructed the box, got the swab tube labelled - the instructions were very clear this label had to go lengthways, not sideways or diagonally, but lengthways. Another barcode went on the outside of the plastic bag with the silver seal and the postage label had to go on the outside of the box but not, I repeat not covering the UN3373 markings. Of course, the label is so large it's almost impossible not to cover these markings and I hope they are just referring to the part that says UN3373 and not the bit that said "Biological Substance Category B" otherwise I'm screwed because it was the only way to get the label to fit on the top of the box. 

Now it was time to take the test. I went and washed my hands as instructed, then using a mirror tried to take the throat sample. I couldn't do it. Just watching the swab go that far back in my mouth was making me gag profusely. I had to pull it out before I retched and it brushed against my lip. Sorry Dr Khan, I fell at the first hurdle. I tried again, and again, and finally managed to get the swab to touch my tonsils. The pressure triggered a retching and I thought I might throw up. I was relieved I'd waited so long after dinner because any earlier and I think I may have done. I composed myself and tried again the swab glanced at the surface and I retched again. I was drooling, the swab touched my inner cheek, it was a mess. Still, I tried again to go to to the other tonsil. I brushed it, I retched. I was done. The swab was clearly contaminated, the sample was not possible to collect. I gave up and moved on to the nose swab.

I had initially found the thought of reusing the swab rather gross and while I still do (I understand scientifically the purpose but it doesn't stop my revulsion) I found myself grateful to take a sample that was not going to make me want to throw up. It was an uncomfortable sensation and it made my nose run more than I had anticipated, but I got this sample relatively easily. Now it was time to put the sample in its tube and pack everything up. I put the tube into its bag and then this bag into its bag. It wasn't clear to me how the silver seal worked - it turned out it was one of those peel-off strips like you get on jiffy bags to reveal the sticky part. In my confusion I forgot to empty all the air out of the bag and so it was quite puffy. I feared it would be too puffy to fit into the very thin box that was provided but I managed to get it in with the help of the security seal. 

Thoughts

So that's the test done. I still have to wait for it to be collected and get the results but the 'tricky' part is done. 

When I heard about the home testing kits I was nervous. I'd heard about how tricky it is to get a medically useful sample from people, even for trained medical professionals and I was worried that putting the test in the hands of untrained amateurs would lead to a high false negative. Nothing I've experienced has allayed those fears in the slightest. In fact, they're heightened. I shall try and go through all my concerns but there are so many it's possible I will forget at least some. 

Let's start with the registration where some sort of credit check software was used to do something unclear in the name of fraud prevention. That may not seem like a big deal unless you have had issues with credit check software in the past. Maybe you've had financial problems, maybe you're not in the country legally, such a check could be intimidating and you decide it's better to not risk the consequences of giving the government that information. 

Then there's the need to book your collection and register your test on different sites run by different companies that both require very similar - but in one important place very different - information. Both sites ask for 'barcodes' but those barcodes are different barcodes. One is the barcode on the collection label, the other is the barcode you will put on the test tube. Doing the test at the end of the day, I got confused and tried to register with the collection barcode. It said it wanted a barcode, that was a barcode that had been provided, why wasn't it working? Because, of course, it wanted the other barcode. 

Next we've got the instructions on actually taking the test. The video is outdated but someone decided that because they still want the samples collected in the same way, who cares if the contents of the home kit have changed? Maybe someone who's unsure of what they're doing, who's sick and worried that they're going to do this wrong. That's who.

Now let's look at the test contents. A test kit containing 9 items, including a box you have to put together yourself, and multiple light and easily lost components is asking for trouble. I understand entirely why it's been done this way - it's cheaper. Flatpack box saves space, not labelling the swab tube and bag before they're sent out means that kits can be compiled quickly, but it means the onus of getting everything labelled correctly is on the person taking the test who, let's remember, is probably feeling quite unwell. 

Moving onto the test itself, I know I have an extreme gag reflex, to the extent that I don't think I'd have done any better in a medical setting, but I also know that providing a single swab and not allowing for mistakes is just asking for contamination. Can you imagine doing this on a sick child? I'd be surprised if even doctors get it right first time every time. 

I did this test as a fairly smart and highly educated person who understands the principles of lab work and who is healthy. The vast majority of people taking this test will be none of those things. They will be people who, quite probably, are feeling very ill and who are frightened for themselves and their loved ones that they might have a deadly disease. They are not going to be in a fit state of mind to read, at minimum, 10 pages of instructions that involve the medical equivalent of 'insert tab A into slot B'. If the position of the barcode on the swab tube is so important, why is it being left to sick people to put it on? If leaving the UN3373 markings need to be uncovered why are they not, at the very least, providing a label that can be easily stuck on the box without covering them? 

Everything about this process scream lowest bidder. And the reason it's the lowest bidder is because they've left it up to the sick person to do all the work for them. 

Conclusions

Applying to get a test is far too complicated and could put people off who are in precarious circumstances. Doing the administration of the test is too complicated. Taking the test is, in the words of Dr Khan, very fiddly, and it seems the throat swab - the part most liable to cause contamination - is unnecessary. Packing the test is too complicated and there are many steps where errors could easily occur that lead to people sending an unusable sample. 

The test is too complicated. I found it stressful and I'm well. 

Why are we relying on outsourced lowest bid companies to supply these tests and sick, scared people to perform them? If we actually care about working out who is well and who is sick then this is not the way to go about it. If, on the other hand, this is a way to funnel public money into private hands while giving the illusion of 'doing something' then I can think of few better ways of achieving that goal.