Coronavirus (COVID-19): Route Map - supporting evidence for the October 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

Test and Protect - the public-facing name for the TTIS strategy and 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, awareness of symptoms, and self-isolating when required to do so.

The COVID-19 testing strategy for Scotland sets out the five priorities for testing:

• 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.

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 and continuing the vital surveillance work to support our understanding of the disease in Scotland.

We have published guidance about the collection of visitor contact details, to assist Test and Protect, for sectors where there is an increased risk of exposure. 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.

We have set out detail of the financial support offered to those on low incomes who are asked to self-isolate.

Local Outbreaks

Managing Public Health Incidents (MPHI) has been updated to reflect the experience of dealing with coronavirus. The Protect Scotland app which was launched on 10 September, signposts to local guidance when users receive an anonymous proximity alert.

Systems

NHS testing is available in all 14 Health Boards and we will soon activate a series of larger Regional Hubs. We now have active weekday NHS lab capacity of over 10,000 tests a day. In addition, we have access to the UK Government Lighthouse Lab Network (LLN), Scotland receives a population-based share of this capacity, currently approximately 20,000 per day. We are working with the UK Government to continue to build laboratory processing capacity to approximately 65,000 tests between NHS Scotland laboratories and the LLN.

Recent surges have placed significant pressure on the LLN resulting in occasional backlogs across the network, which in turn can have knock-on effects on the performance of the overall system, leading to delays to contact tracing and getting contacts to isolate. In the period of time of concern of this Evidence Review capacity issues across the LLN on weekend of 25-27 September caused an increase in turnaround times of between 48 and 72 hours in the following days. We have implemented a range of measures to mitigate this. Principally, we have begun to migrate routine testing of care home staff into NHS Scotland laboratories. This will reduce demand for our share of Lighthouse lab network capacity, allowing that to support other sampling routes.

The UK Government has established 6 Regional Testing Centres and a pool of 18 Mobile Testing Units in Scotland. We are also establishing 22 walk-through test sites which will support sampling capacity for areas with low car ownership.

As a consequence of the rapid increase in positive cases picked up through testing, as set out under criterion 1 above, the contact tracing system has come under increased pressure as we have continued to scale up capacity. We are working closely with Public Health Scotland to support NHS Boards to continue to build local capacity, including delivering support at a national level through the National Contact Tracing Centre (NCTC). From Saturday 10 October, Test and Protect temporarily moved to a system of contacting all close contacts of those who tested positive via SMS only. This has allowed contact tracers to prioritise calling all positive individuals and has helped ensure close contacts of index cases received instruction to self-isolate promptly. Further system efficiencies and workforce surge capacity is also being explored to ensure the system will be able to continue to withstand further pressures.

Contact Tracing App

Following growing international evidence, and a number of academic modelling studies, that showed the additional benefits that proximity tracing apps could have on speeding up the contact tracing process, we launched Protect Scotland on 10 September 2020. Close to 1.5 million people have now downloaded the app. This represents 33% of all over 16s in Scotland (or 27% of the whole population) – well over the level at which the academic modelling shows the app will start to have an affect (at least 15% of the population).

And we know the app is working as intended. As of 13 October, 39% of all people in Scotland who have tested positive since Protect Scotland was launched have been app users. This has resulted in 5,449 close contacts receiving an alert via the app advising them to self-isolate.

At this stage, we have no way of knowing how many of those close contacts would have been otherwise identified through traditional contact tracing. It is highly likely that a proportion will be truly unknown contacts who would not otherwise have been identified. It is also highly likely that the majority of 'known' contacts would have received their notification before they were subsequently contacted via the manual process, although this is dependent on the speed at which the app user who tested positive entered their unique test code into the app.

We are close as well to ensuring Protect Scotland works with similar apps across the UK and other countries, enabling people to travel across borders whilst still benefiting from the Protect Scotland app. We also aim to expand the app to under 16s, and engagement on this continues

Data (valid as at 4^th October)

14,997 individuals (15,901 cases) were recorded in the contact tracing software and 65,755 contacts have been traced, of which 48,243 were unique contacts.

Our data demonstrates that the system has reached 93% of index cases and 93% of close contacts between 22 June and 11 October. It therefore continues to be the case that the vast majority of index cases and contacts are reached and only a small proportion cannot be reached. Notwithstanding the above, there are indications from the data that end-to-end turnaround time is dropping as a result of the high increase in daily positive cases, and as a result of testing backlogs in the LLN.

The Protect Scotland proximity tracing app is issuing close contact alerts, potentially further speeding up the process and identifying potentially previously unknown contacts.

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 4.1 per case and 4.4 per individual. The latter has been steadily decreasing since 13 September where the cumulative average number of contacts was at its highest at 5.12, as illustrated by the below table (Source: Public Health Scotland COVID-19 Statistical Reports).

period start	period end	Contacts per case	Contacts per individual	Contacts per individual, matched
28-May	07-Jun	1.24
	14-Jun	1.25
	21-Jun	1.25
	28-Jun	1.34		3.10
	05-Jul	1.42	2.72	3.64
	12-Jul	1.49	2.73	2.90
	19-Jul	1.51	2.70	3.22
	26-Jul	1.72	2.96	4.22
	02-Aug	2.10	3.40	5.91
	09-Aug	2.48	3.76	5.36
	16-Aug	2.90	4.06	5.49
	23-Aug	3.31	4.33	6.02
	30-Aug	3.62	4.51	6.15
	06-Sep	4.21	5.00	5.78
	13-Sep	4.45	5.12	4.98
	20-Sep	4.48	4.99	5.13
	27-Sep	4.40	4.77	4.06
	04-Oct	4.14	4.38	N/A

As testing capacity has continued to increase, more people are now tested daily than at the start of the pandemic. We may be still seeing lower than actual levels of symptomatic people booking a test however, so work is underway to better inform and motivate people to be tested.

Funding

We have confirmed funding of £1.1 billion to address financial pressures arising in response to COVID-19 across the Health & Care sector. This funding ensures the sector will continue to receive the support required to deal with the additional challenges of the pandemic, whilst still delivering the vital health, social care and hospital-based services the public rely on every day.

We will undertake a further substantive funding allocation in January. This will provide the opportunity to better understand the implications of COVID across the sector for the remainder of this financial year and ensure frontline services continue to have the funding they require.

In conclusion:

The Test and Protect contact tracing system has been introduced across all health boards using established and effective contact tracing techniques. As case numbers have risen, we have continued to invest in our National Contact Tracing Centre and Health Boards to ensure staffing can meet demand over the coming period, and ensured mutual aid arrangements are in place between health boards which ensures support is in place to meet local surge demand.

On the basis of the evidence summarised above the assessment is that while public health capacity to find, test, trace and isolate have come under more pressure in this period, including periods where turnaround times exceeded those required for optimal public health interventions to reduce chains of transmission, overall and on balance, considering the range of mitigating actions and additional capacities such as the Protect Scotland app, Criterion 2 continues to be met at this review point.