Abstract
BACKGROUND: Effective disease surveillance is essential for understanding pathogens' epidemiology, detecting outbreaks, and enabling timely public health responses. In the United Kingdom, large-scale studies, such as the Office for National Statistics COVID-19 Infection Survey (CIS), have monitored SARS-CoV-2 transmission but required significant resources, making them challenging to sustain when pandemic-specific funding ends and also in resource-limited settings. In contrast, the Virus Watch study, at lower cost, relied on self-reported and linked national testing data as well as symptomatic testing, while Severe Acute Respiratory Infections Watch (SARI) leveraged hospital data for cost-effective surveillance. OBJECTIVE: This study aimed to evaluate the effectiveness of Virus Watch as a surveillance system in monitoring COVID-19 positivity, incidence, and hospitalization rates in England and Wales, using data from the CIS and SARI as benchmarks for comparison, while considering the key differences in the study designs, including recruitment strategies, incentives, and testing criteria. METHODS: We used the Virus Watch prospective community cohort study to estimate COVID-19 positivity, incidence, and hospitalization rates in England and Wales from June 2020 to March 2023. Rate estimates were compared with CIS modeled positivity and incidence rates, and with SARI COVID-19 hospitalization rates. Global synchrony between datasets was measured using overall Spearman ⍴ and local synchrony using 9-week rolling Spearman ⍴. For England, comparisons with CIS estimates used Virus Watch rates calculated with and without linked national testing data. Positivity rates were also assessed overall and separately before and after the end of free national testing. RESULTS: A total of 58,628 participants were recruited into the Virus Watch study, of whom 52,526 (89.6%) were resident in England and 1532 (2.6%) in Wales; region was missing for the remainder. Virus Watch-estimated COVID-19 positivity and incidence rates in England, calculated with and without linked testing data, showed strong global synchrony with CIS estimates (positivity ⍴: 0.91 and 0.90; both P<.001 and incidence ⍴: 0.92 and 0.90; both P<.001) and strong local synchrony (positivity ⍴: median 0.75, IQR 0.53-0.85 and median 0.67, IQR 0.47-0.83, and incidence ⍴: median 0.76, IQR 0.49-0.88 and median 0.66, IQR 0.45-0.82), despite having lower absolute values. Global and local synchrony of positivity rates were similar for periods before and after the end of free national testing, although the difference between Virus Watch and CIS estimates was greater post-free testing. COVID-19 hospitalization rates were also lower and less synchronized with SARI estimates. In Wales, Virus Watch estimates exhibited greater variability (positivity ρ: 0.75, P<.001; incidence rate ρ: 0.85, P<.001) and lower local synchrony (positivity ρ: median 0.61, IQR 0.34-0.74, and incidence ρ: median 0.52, IQR 0.38-0.71) compared to England. CONCLUSIONS: Our results highlight the effectiveness of the Virus Watch approach in providing accurate estimates of COVID-19 positivity and incidence rates, even in the absence of national surveillance systems. This low-cost method can be adapted to various settings, particularly low-resource ones, to strengthen public health surveillance and inform timely interventions.