Coronavirus (COVID-19): Scotland's route map - supporting evidence for moving to Phase 3

WHO criterion 2: Sufficient public health and health system capacities are in place

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 paper COVID-19 - Test, Trace, Isolate, Support (TTIS), which sets 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.

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.

Test and Protect was introduced across all Health Boards from Thursday 28 May. As of 5 July, we have undertaken contact tracing for 1,506 index cases, representing 785 individuals, identifying 2,136 close contacts and asking them to isolate. We have introduced new digital tools to support contact tracing, and have started the roll out of the national contact tracing support service.

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.

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 enables 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 that 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.

Local Outbreaks

Careful consideration is being given to the ways in which we can prepare for when different restrictions prove necessary for local lockdowns in different geographical areas. That has been tested in the experience around Gretna and worked well, both locally in speed and effectiveness of response and nationally through Scottish Government Resilience Room (SGoRR) arrangements. Criteria for triggering local lockdowns, strong understanding of data, clear public communication, clear escalation criteria and understanding of effective compliance are key.

Systems

Since the start of the epidemic we have significantly increased our testing capacity - the original capacity was 350 tests a day. We now have active weekday NHS lab capacity of around 10,000 tests a day and weekend capacity of around 8,000 tests a day. In addition, we have further capacity through the Glasgow Lighthouse Lab that has capacity to process approximately 20,000 tests a day and may process tests taken from across the UK.

National Services Scotland is continuing to develop lab partnerships to further build Scotland's testing capacity. All 14 Boards across Scotland have flexible contact tracing arrangements in place, and all are ready to flexibly support any localised increases in community transmission of the virus that may occur as we take steps to ease lockdown restrictions.

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

Support

We have introduced new reporting processes for Health Boards that will give us more robust data on testing for key workers and staff, hospital, and care home testing, which will help inform local and national planning and allow us to see where there are gaps.

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 and UKG Social Care Testing Portal.

Health Boards and NHS National Services 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 also working with NHS Boards and health care partners on restarting health care services, meaning that capacity is required for additional testing.

The Route Map states that "we will provide information to the public about increases in transmission and significant clusters of cases". Senior Medical Officers (SMOs) have been asked to advise the clinical view on public sharing of information on outbreaks as an expanded Test and Protect approach is implemented.

Digital technology continues to play a vital support role. The initial focus was on ensuring the contact tracing staff were suitably equipped with the relevant software, and that data was able to effectively flow across the system. Both aspects are now up and running, with local teams able to use a tool that integrated with the existing data infrastructure since 28 May. The core enhanced national system went live on 22 June in Grampian; the full roll out is expected by mid-July.

In addition to the tools already developed for local contact tracing staff, we continue to develop online versions of the contact tracing forms for use by the public. Once available, and if required, those who test positive for COVID-19 will be sent a link to the online digital tool in order to pre-populate information on contacts ahead of their call with a contact tracer. At this stage, although it is public-facing, this online form will not be publicly available for general use. The initial intention is that it will only be sent to those who have tested positive. This tool is not a standalone app, rather it will be an online form accessible from any device with an internet connection.

We also recognise that not everyone in Scotland will want, or be able, to use digital technology in this way, and so telephone support remains available for everyone who needs it.

Data

Between 28 May and 5 July, 1,506 cases (positive test results) were identified for Test & Protect. Of these, 785 were unique individuals from which 2,136 contacts have been traced. This means about 2.72 contacts per person have been traced.

The average number of contacts traced per person are around early estimates of the number of contacts a person has at this stage of lockdown, but below the number of contacts expected with no restrictions in place. This could be due to:

• As some lockdown measures remain in place, many index cases are in close contact with fewer people.
• Those engaging with the system are not reporting all contacts.

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, a continuing and sustained decline in transmission 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, 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.