Coronavirus (COVID-19): Scotland's Route Map - supporting evidence - 20 August 2020 review

WHO criterion 2: Sufficient public health and health system capacities are in place to identify, isolate, test and treat all cases, and to trace and quarantine contacts.

Test & Protect

On 4 May the Scottish Government published its COVID-19 - Test, Trace, Isolate, Support (TTIS) paper setting out the approach to controlling the spread of coronavirus in the community. The public-facing name for the TTIS strategy is Test and Protect. It is a public health approach to supporting the management of outbreaks of infectious diseases. It is used to interrupt chains of transmission in the community.

Test and Protect – our direct response to this criterion – launched on 28 May. Test and Protect relies on disease prevalence being low, as well as high levels of public compliance with public health advice including hand and respiratory hygiene, physical distancing and awareness of symptoms.

Scotland's approach to tracing uses established, tried and tested contact tracing techniques, delivered by health protection professionals in local teams, with support arrangements at national level.

All 14 Health Boards across Scotland have flexible contact tracing arrangements in place. They are all ready to support any localised increases in community transmission of the virus that may occur as we take our first steps to ease lockdown restrictions.

Policy interventions

Our approach to testing is focussed on saving lives and protecting the vulnerable, rolling out Test and Protect to interrupt chains of transmission in the community and continuing the vital surveillance work to support our understanding of the disease in Scotland. This is enabling us to continue to expand eligibility for testing, and ensure the necessary capacity exists to support Test and Protect. We are continuing to model what capacity is required in the system to ensure that capacity meets demand and to avoid delays anywhere in the system.

Now Test and Protect has been rolled out, we will continue to work with partners to ensure that everyone who lives in Scotland can access testing. Our health protection teams are experienced in contact tracing across UK and international boundaries. Those teams will continue to work with their counterparts in other areas to deliver effective contact tracing services. We have confidence that people will recognise the importance of taking part in order to protect themselves and each other, just as they have with lockdown.

We have published guidance for the hospitality sector about the collection of customer contact details to assist Test and Protect if required. The guidance was developed in consultation with the hospitality industry and ensures data protection principles are upheld. This will enable the Test and Protect service, in the event of an outbreak, to get in touch with anyone present at the same time as an individual who tested positive, thus enabling us to break chains of transmission of the virus.

Local Outbreaks

Scotland has well established processes for addressing outbreaks of infectious disease. Managing Public Health Incidents (MPHI) has been updated to reflect the experience of dealing with coronavirus. MPHI sets out in detail the role of local agencies in addressing local outbreaks, the role of Incident Management Teams and the escalation process for more serious or widespread outbreaks.

The recent number of outbreaks across Scotland have shown how the local response has managed these proportionately. The outbreak in Gretna was managed by reimposing guidance on travel restrictions and gatherings, while the more significant outbreak in Aberdeen required imposition of more rigorous statutory restrictions, with provision in regulations.

Dealing with these outbreaks has demonstrated that criteria for triggering action, strong understanding of data, clear public communication, clear escalation criteria and understanding of effective compliance are key.

Systems

Since the start of the pandemic we have significantly increased our testing capacity – original capacity was 350 tests a day. We now have active weekday NHS lab capacity of around 12,006 tests a day (around 10,500 on weekend days) and around 28,000 tests a day from the Glasgow Lighthouse Laboratory, providing overall normal weekday capacity of circa 40,006. The Glasgow Lighthouse Laboratory may process tests taken from across the UK.

This increased testing capacity has enabled us to continually expand eligibility for testing, and ensure the necessary capacity exists to support Test and Protect. Testing of symptomatic individuals was expanded to include children under 5 years of age on 22 July.

We are continuing to model what capacity is required in the system to ensure that capacity meets demand and to avoid delays anywhere in the system.

Health Boards and NHS National Services Scotland (NSS) are working hard to manage demand across different geographies and maximise daily capacity. This includes using real time data to allow variances in capacity and demand to be managed.

We are working closely with Public Health Scotland to support Boards to continue to build local capacity, including delivering support at a national level in the form of a National Contact Tracing Centre (NCTC). The NCTC was rolled out across all Boards by 17 July.

NSS are continuing to develop lab partnerships with all sectors of Scottish society to further build Scotland's testing capacity.

Where there are outbreaks, these are investigated through a risk assessment which takes into account patient confidentiality, public health needs and individual consent issues. Each incident is judged individually. There is scope to make the public aware of incident where appropriate. Anonymised information is used if it is practicable to do so and if it will serve the purpose, and index cases are always asked for permission to disclose their personal details.

Support

We are working with NHS Boards and health care partners on restarting health care services and will ensure there is sufficient capacity to manage additional testing. To enable the remobilisation of the NHS, we will regularly test staff working in specialist cancer units, in long-term care of the elderly, and in long-stay mental health wards. We are also testing any health care staff connected to a nosocomial outbreak regardless of symptoms. This testing began on 8 July.

Discussions are under way between health boards and clinical teams about testing patients before surgery, alongside all staff involved in a patient's treatment.

We are continuing to work closely with Board Chief Executives and Directors of Public Health to ensure access to resources to increase testing capacity including Mobile Testing Units (MTU) & UKG Social Care Testing Portal.

All health boards are using the digital tools to support contact tracing. We continue to enhance and develop these tools - adding more sophisticated management tools - for use solely by our contact tracing staff. We are also separately developing public-facing versions of these simple tools and users will be involved in the design of these.

The Cabinet Secretary for Health and Sport announced on 31 July that a contact tracing app to support NHS Scotland's Test and Protect system is now in development and will be made available in the autumn. The decision to develop our own app followed careful consideration of all the options open to us, and took into account the undoubted additional benefits that anonymous contract tracing technology can offer Scotland's tried and trusted Test & Protect service. The app will be developed by NearForm using the same software as the Republic of Ireland contact tracing app, which has already been adapted for use in Northern Ireland and Gibraltar and will work with those apps to support movement across the common travel area. The app will offer us an additional tool to support contact tracing efforts and notifies users via Bluetooth technology when they may have been in close proximity with someone who has tested positive for Covid (within 2 metres for 15 minutes or more).

Data

Data valid as of 19 August:

1,835 individuals (2,570 cases) were recorded in the contact tracing software and 7,449 contacts have been traced.

The initial data showed that the average number of contacts per positive case is 1.49; this is what we should expect to see during Phase 1 and 2 of lockdown restrictions. This has now increased to 4.06 as lockdown restrictions eased further in Phase 3, and reflecting recent outbreaks. For the most recent week of data, the average number of contacts per individual is 5.12. This newly-published figure gives us a more accurate reflection of the number of contacts that people have had in the most recent week.

The Scottish Government is working with PHS to understand what data breakdowns are available to identify more local outbreaks.

A sustained decline in transmission has allowed the implementation of a robust system of testing on the basis of significantly expanded capacity. Fast, well trained and effective contact tracing teams are in place; outbreak reporting and monitoring systems have been agreed and implemented; and data systems have been established to ensure that contact tracing is as reliable, rapid and effective as possible. We may be seeing lower than actual levels of symptomatic people booking a test so work is underway to better inform and motivate such people to be tested, in addition to work to make test sampling easier.

In conclusion:

Continuing low prevalence, albeit with a small but sustained increase in daily cases, coupled with expanded testing capacity has allowed the implementation of a robust testing system.

We have published an updated Testing Strategy setting out the role testing continues to play in tackling the pandemic.

An efficient Test and Protect and contact tracing system has been introduced across all health boards which uses established and effective contact tracing techniques, delivered by health protection professionals in local teams, with support arrangements at national level.

Localised outbreak reporting and monitoring systems have been agreed and implemented; and data systems have been established to ensure that contact tracing is as reliable, rapid and effective as possible.

On the basis of the evidence summarised above the assessment is that this Phase 3 criterion continues to be met at this review point.