Coronavirus (COVID-19): Route Map - supporting evidence for the 10 September 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 and we use this to interrupt chains of transmission in the community.

Test and Protect – our direct response to criterion 2 – launched on 28 May. This system relies on disease prevalence being low, balanced with high levels of public compliance with public health advice including hand and respiratory hygiene, physical distancing and awareness of symptoms.

Our testing approach has adapted as the pandemic has progressed and as we navigate our way out of lockdown. The COVID-19 testing strategy for Scotland covers testing for the following reasons:

• whole population testing of anyone with symptoms (Test & Protect);
• proactive case finding by testing contacts and testing in outbreaks;
• protecting the vulnerable and preventing outbreaks in high risk settings by routine testing;
• testing for direct patient care, to diagnose and to treat, and to support safe patient care as NHS services restart; and
• surveillance to understand the disease, track prevalence, understand transmission and monitor key sectors.

All 14 territorial Health Boards across Scotland have flexible contact tracing arrangements in place, supported by the National Contact Tracing Centre. The capacity of the contact tracing workforce is kept under constant review to be able to flexibly support any localised increases in community transmission of the virus that may occur. This means that staffing will increase or decrease due to demand and that not all of them will be required at any one time. Our data demonstrates that the system is working well, with 99.1% of index cases and 98.2% of close contacts reached by the contact tracing service between 22 June and 6 September. This is of particular note as we have been able to identify chains of transmission of the virus across the country – which has in turn informed our response to outbreaks and guided the way in which we address the ongoing pandemic.

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 we meet demand and 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 about the collection of visitor contact details, to assist Test and Protect if required, for sectors where there is an increased risk of exposure, including tourism and leisure settings, and places of worship. Further, we have made it mandatory for food and drink hospitality settings to collect visitor contact details, and to share these with NHS Test and Protect if relevant, to support contact tracing. 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.

Following the publication of the Scottish Testing Strategy on 17 August, work is in train to expand testing eligibility to also include asymptomatic close contacts in a move towards more proactive case-finding, recognising selected asymptomatic testing has high levels of potential benefit for the strategic aim of suppressing transmission to the lowest levels possible. This additional eligibility will be turned on as soon as we have confidence there is sufficient testing capacity to meet the increase demand, likely in the coming couple of weeks when the pressures on current testing – in part driven by the return of schools – have stabilised.

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.

Where there are outbreaks, these are investigated through a risk assessment which takes into account patient confidentiality, public health needs and individual consent issues.

As with most countries impacted by COVID-19, Scotland has also seen localised outbreaks of the virus following the lifting of lockdown restrictions. Most recently, we identified two outbreaks (Aberdeen; Glasgow, East Renfrewshire and West Dunbartonshire) which, following clinical advice, led us to implement localised restrictions in an attempt to reduce the spread and contain the outbreak.

The recent outbreaks across Scotland have shown how the local response has managed these proportionately. The outbreak in Aberdeen was managed by the re-imposing of rigorous statutory restrictions, with provision in regulations. In comparison the recent measures introduced in Glasgow and surrounding areas, were managed by re-imposing restrictions on visiting other households. The different approaches taken were informed by clinical assessments of the main causes of the respective outbreaks: a large number of positive cases associated with the hospitality sector (both clients and staff) in the case of Aberdeen and a significant number of smaller household-related outbreaks in the case of Glasgow, East Renfrewshire and West Dunbartonshire.

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 to managing the pandemic and protecting the wider population from further spread.

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). In addition we have UK Government capacity through the Lighthouse Lab network, including the Glasgow Lighthouse Lab which has capacity to do 28,000 tests per day. Scotland receives a population-based share of this capacity, which is currently approximately 12,000 per day.

The UK Government has established 6 Regional Testing Centres and a pool of 18 Mobile Testing Units in Scotland. Any symptomatic individual can access testing via the programme. The Scottish Ambulance Service took over responsibility for the operation of mobile testing units in Scotland from the Army on 1 September 2020. We are continuing to work closely with Board Chief Executives and Directors of Public Health to ensure access to resources to increase testing.

A recent UK-wide surge in testing demand has put greater pressure on existing capacity, leading to temporary shortages of capacity at UK testing sites. We had anticipated that fluctuations in demand would place pressure on the testing system and we were able to activate contingency plans which rapidly brought additional capacity online in Scotland. The surge in demand has also resulted in significant delays in turnaround times on tests conducted through the UK Government programme and we have raised this as a significant concern with the UK Government.

Scaling up of Lighthouse capacity across the UK has been slower than expected. We are working with the UK Government to continue to build sampling pathways, and to build laboratory processing capacity to approximately 65,000 tests between NHS Scotland laboratories and the Lighthouse Lab in Glasgow. It is expected that the Glasgow Lighthouse Lab will still reach 40,000 daily capacity by November 2020. We will continue to work closely with UK officials to secure increased capacity in the Glasgow Lighthouse lab. Care home staff testing will now be carried out by the NHS. This will ensure quicker turnaround times in for care home staff, reduce false positives and to enable timeous action where required.

Following high levels of demand across the UK, we are working closely with Health Boards to provide additional capacity and alternate routes to the UK Government programme. This includes the mobilisation of academic and commercial nodes and the launch of three Regional Hubs this year. We are also working with boards to put in place alternative arrangements for routine testing of care home staff and are assessing a number of options to increase capacity and reduce turnaround times.

Testing of symptomatic individuals was expanded to include children under 5 years of age on 22 July and we are preparing to further expand eligibility for testing to all close contacts identified through contact tracing, once capacity allows. This will strengthen our case finding abilities and will help identify and break further chains of transmission faster.

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. The UK Government announced on 3 August the roll out of two rapid COVID-19 tests, which can provide results in 90 minutes, and discussions are ongoing about the deployment of these tests to Scotland.

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. As case numbers have been increasing, we have increased resourcing for the National Contact Tracing Centre and continue to staff up our national contact tracing workforce to be able to adapt and respond. In response to the increase in international arrivals needing to quarantine, we are providing a further £1 million to recruit up to 25 new contact tracers to allow the NCTC to recruit additional staff into the team which will be dedicated to quarantine follow-up calls. In parallel, the NCTC has a further 30 staff joining as contact tracers over the next fortnight. This is part of planned increased capacity to handle anticipated increases in positive test results due to more testing. Simultaneously, all boards keep the deployment of their own contact tracing staff under review and there are mutual aid arrangements in place across NHS Scotland to ensure sufficient capacity can be redirected to meet demand.

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 incidents 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.

Contact Tracing App

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 was in development and may be made available to the Scottish public as soon as 10^th September. 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 simple Proximity tracing App named Protect Scotland has been developed by NearForm using the same software as the Republic of Ireland's 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).

The Scottish Government has committed to engaging with the UK Government regarding the potential of a UK-wide contact tracing App and working towards ensuring that the Scottish App is interoperable across the UK.

The App is free to download, no personal identifiable information is entered and it does not monitor the location of individuals. The App produces aggregated and anonymous Scotland-wide metrics that will enable the Scottish Government and Public Health Scotland to better understand the spread of the virus and plan accordingly, in particular:

• The total number of App users
• The total number of instances where an App user has registered a positive test result and has consented to upload the encrypted anonymous random codes that will be used to alert other App users that they have been in close contact with over the last 14 days (this is also referred to as 'uploading diagnosis keys')
• The total number of alert notifications triggered (this is also called 'exposure notifications').

As it is entirely voluntary to sign up and download the App we appreciate that we are relying on the honesty and participation of the public in order to achieve an effective outcome and reliable tracing system via the App. As with the decision to develop the App, careful consideration has been given to the roll-out and data protection aspects of this digital tool so that we can maintain public trust, raise awareness of the spread of the virus and ensure that we are reaching a broader section of the population.

Data

Data valid as of 7 September:

3,970 individuals (4,707 cases) were recorded in the contact tracing software and 15,197 contacts have been traced.

The average number of contacts per positive case was 1.49 initially; this is what we should expect to see during Phase 1 and 2 of lockdown restrictions. This is now to 5.0 as lockdown restrictions eased further in Phase 3, and reflecting recent outbreaks. For cases generated in the week commencing 24 August, the average number of contacts per individual was 6.1.

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.

An efficient Test and Protect and contact tracing system has been introduced across all health boards which uses established and effective contact tracing techniques. As case numbers have gone up, we have continued to invest in our National Contact Tracing Centre to ensure staffing can meet demand, and ensured mutual aid arrangements are in place between health boards which ensures support is in place to meet local surge demand.

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.