Coronavirus (COVID-19) Scotland's Strategic Framework update – February 2022: evidence paper

6. Looking to the future

6.1 Introduction

This section of the paper looks to the future. It starts off by examining scientific developments, presents the latest evidence on non-pharmaceutical interventions, looks at evolving public attitudes and expectations and considers issues of inequalities. As all countries are grappling with pandemic management there is a summary of the experience of other countries facing the same challenges.

Having presented updated evidence on the tools available to manage the pandemic, the next stage is to consider a range of plausible futures using a ‘four worlds’ model to illustrate what the future may hold and to outline the various implications of each scenario. These futures are not predictions but useful heuristic tools to support planning.

Data and analysis has played a key role in managing the pandemic to date. For the future there will be a need to develop a suite of indicators that can be used as signals of change and consider how these are reported. Finally, learning from previous experience enables enhanced management in the future and brief details are set out about how this will be achieved.

6.2 The evolving science and trajectory of the epidemic

Almost two years into the SARS-CoV-2 pandemic, it’s now accepted that the most likely future scenario for the virus and its associated disease, COVID-19, is one of transition to become endemic, rather than achieving regional elimination.

This means that the virus is not expected to disappear but will be always present in a population within a geographic area^[196]. However, it is not known how long the transition to a relatively stable endemic state will take, and how this transition will be in terms of incidence and disease severity. Endemic diseases are not only mild in severity, they can be both widespread and cause serious illness and death (e.g. malaria or tuberculosis)^{[197] [198]}.

Once endemic, it is likely that SARS-CoV-2 will have winter peaks of varying size and circulate alongside influenza and other respiratory viruses. Previous pandemics involving influenza have lasted 1-3 years. Pathogens arising from these, such as influenza A H1N1 (1918), influenza A H3N2 (1968), influenza A H1N1 (2009) moved on to become endemic with winter peaks in incidence that were largely predictable^[199]. After the initial waves these diseases were associated with declining fatality rates partly due to immunity from natural exposure and vaccination tailored towards the anticipated changes and dominant strains.

An optimistic view for SARS-CoV-2 is that enough people will develop and retain sufficient natural or vaccine mediated immunity to prevent large scale hospitalisation and death and that this may also assist in reducing transmission. However this would only be the case if a variant which escapes natural and vaccine immunity does not present itself. Even without an escape variant it is hard to anticipate how long it would take to reach a situation where SARS-CoV-2 falls into an annual cycle like influenza which could be many years.

SARS-CoV-2 is likely to become the fifth coronavirus that infects humans to become endemic; previous types have demonstrated seasonal waves of infection but to this point it has been unclear whether they do so through waning immunity or viral mutation and immune evasion. More recent studies suggest that it is this latter mechanism that is the most important and is best seen in the study of coronavirus 229E. The emergence of Delta and Omicron variants of SARS-CoV-2 strengthen this theory^[200].

New lineages of SARS-CoV-2 have replaced the pre-existing dominant variant very rapidly. In Scotland, Alpha was replaced by Delta which was then replaced by Omicron, all of which were genetically distinct and from different antigenic clusters, see Figure 27– SARS-CoV-2 lineages; Figure 28 - variants in Scotland. This instability and higher degree of antigenic “shift” or “jump” means that it is much more difficult to predict what future scenario we are most likely to face. The next variant of global importance may not be an offspring of Omicron. Although Omicron is less severe than the previous variant Delta, it is not a given that SARS-CoV-2 will continue to become less severe over time, and it is possible that the next variants will be more severe and may evolve from the wild-type strain or another lineage.

The figure was made using data accessed on 31 January from the public COG-UK data set ^{[203] [204]} using an R script adapted from Dr Samantha Lycett, Roslin Institute, University of Edinburgh^[205].

The genomes of viruses change over time through a number of mechanisms, sometimes resulting in small changes in the genome of the virus and sometimes resulting in larger changes and the emergence of new variants. In immunocompromised people, infections and therefore the replication of virus may be prolonged. This increases the potential for emergence of variants. Case studies have documented the emergence of unusually high numbers of genetic changes in immunosuppressed individuals treated with convalescent plasma. All the current SARS-CoV-2 VOCs have multiple mutations across the genome. Single point mutants on top of VOCs such as Alpha and Delta have not (yet) emerged to dominate over the existing VOCs. This implies current variants either evolved during long term persistent infection, or under circumstances of intense transmission with wide selection bottlenecks or in places of sustained but undocumented transmission^[206].

The number of emerging variants will depend on the number and stringency of disease control measures adopted by Governments. Global vaccination is likely to reduce the global incidence and therefore the likelihood of emergence of variants however, it is yet unknown how levels of vaccination affect the relative risk of the emergence of immune escape variants^[207].

At this stage in the pandemic, with high population immunity as a result of natural exposure and vaccination, it is more likely that the future evolutionary path will be one that will promote immune evasion^[208]. The outcome would be seasonal waves, propelled largely by spread in older adults, who could develop severe symptoms. Annual vaccination would reduce disease severity and slow transmission, but fast evolution would mean the vaccines wouldn’t always be well matched to circulating viral strains^[209]. The fast spread of a variant would increase the population’s immunity but it could also create favourable conditions for emergence of new potentially more severe, more transmissible, drug resistant or vaccine escaping variants^[210]. However, there is a limit to the amount of changes to the virus genome that can occur for it evolve into a more efficient variant.

With antiviral therapies becoming more widespread, it is likely that adaptation to evade therapy in addition to immunity are going to become more important for this SARS-CoV-2, and therefore surveillance to monitor drug resistance and vaccine escape are going to be more critical as we move toward a more stable endemic state.

In the short to medium term, it is likely that the Omicron variant will work in our favour; a very transmissible but less virulent variant that may act to increase natural immunity in the population that may protect us to a degree and offer a period of relative stability, particularly as we approach spring and summer 2022.

However, in the longer term, population immunity will wane and new variants may additionally become more immune evading. It is possible that we will see further waves of infection and some may be severe, especially after population immunity has decreased. During the dynamic phase of transition, another major antigenic shift with sufficient ability to confer significant immune escape is almost certain to trigger a large wave of infection and this may not be seasonal if the degree of immune escape is substantial.

6.3 Variant surveillance

Variants of concern (VOCs), variants being monitored (VUMs) internationally^[211] and the number of new variants in each of the 4 nations in the UK are reported weekly^[212]. UKHSA also publish risk assessments of variants indicating their biological properties and giving a level of risk for different properties and an indication of confidence of the assessment^[213].

New variants are identified by genomic sequencing, and variants are monitored using genomic sequencing, genotyping (allele specific PCR detection of specific mutations) or a proxy (such as SGTF)^[214]. Currently sequencing in Scotland is carried out on a surveillance sample of PCR positive cases. Samples from patients in hospital, and international travellers are prioritised.

Adequate surveillance, internationally and domestically, both at borders and across the population is needed to provide early warning of emerging variants. Borders surveillance in particular is important, with effective genomic sequencing provision of positive cases from international travellers.

Genomic sequencing of wastewater is being undertaken as a research programme. Samples from locations covering approximately 70-75% of the population of Scotland are being sequenced weekly to identify dominant variants and to detect VOCs and VUIs.

6.4 Vaccinations

NERVTAG (New and Emerging Respiratory Virus Threats Advisory Group), via SAGE published advice on three likely routes of potential long term evolution of the virus in July 2021^[215]. One of the proposed scenarios describes a variant which could cause severe disease in a greater proportion of the population than has occurred to date. The second scenario assumes emergence of SARS-CoV-2 variants which are able to escape immunity elicited by past strains or vaccination. The third option talks about emergence of a drug resistant variant after the expanded use of anti-virial therapies. SAGE suggested a number of potential solutions to each scenario which involve regular vaccination schedules, ongoing vaccine development to ensure continued good levels of protection and reducing transmission to minimise risk of recombination and introduction of new variants.

SAGE 105 meeting minutes, published on 11 February 2022, included an update on the long-term evolution of the virus. They comment that variants will continue to emerge, and that the scenarios listed above remain valid, including the emergence of variants that are less susceptible to current vaccines, resistant to antiviral drugs, or with differing disease severity (high confidence). The milder disease associated with Omicron may be an exception and new dominant variants may have disease characteristics similar to Delta for example. They suggest that future dominant variants may evolve from variants that are not part of the current dominant global landscape. They recommend further analysis of the origin of different SARS-CoV-2 variants, particularly focused on immune compromised hosts where longer term (persistent) infections can become established that could assist viral evolution, along with potential zoonotic crossover events from animal to human. They also recommended that antiviral therapies should only be used when necessary and that if a highly immune escaping variant emerged, access to effective antivirals will be critical (medium confidence)^[216].

To date, all licensed vaccines in the UK have been designed based on the original strain of SARS-CoV-2 that was circulating in Spring 2020. However, there are many vaccines in development worldwide at different stages of the clinical trial and regulatory pipeline^[217].

Waning immunity is when a person’s immune response decreases over time after an initial infection or vaccine^[218]. Data from numerous studies indicate that neutralising antibodies last from 5-7 months^[219] for up to one year^[220] after SARS-CoV-2 infection. Individuals with severe illness produce more antibodies^[221] and vaccination of individuals who have already been infected induces higher levels of protection than following vaccination alone^{[222] [223]}. However, Omicron can infect people who have been vaccinated or who have had a previous infection more readily than compared to previous variants such as Delta^[224]. We do not know how long vaccines will work to give good protection against hospitalisation and death, but there is evidence that vaccine effectiveness decreases with time, and antibodies start to decrease several weeks or months after the second and third vaccine dose^[225] (see section 2.3).

Pfizer and BioNTech have started clinical trials of a new SARS-CoV-2 vaccine that specifically targets the Omicron variant. Moderna are planning to begin trials of its own Omicron-specific vaccine and the University of Oxford and AstraZeneca have also started working on a new version of their vaccine^[226].

It is also important to invest in vaccines which provide cross-protection against a broader spectrum of variants and potentially other coronaviruses, and maintain capacity to rapidly develop vaccines with updated or different spike protein variants^{[227] [228]}. Early studies on immune responses in mice (non-peer reviewed) reported that antibodies elicited through Omicron infection or Omicron specific vaccines were not effective at inducing an immune response against other SARS-CoV-2 variants^{[229] [230]}.

There are many possible innovations in vaccine development, for example, vaccines which are more effective against infections and produce a longer lasting immune response would be very useful^[231].

Examples are the vaccine in development by Valneva which contains an adjuvant which may help to make it more effective in older people^[232] and Vaxart are developing an oral vaccine which could tackle the issue of needle phobia^[233].

Akston Biosciences have recently received approval to conduct a Phase II/III clinical trial for a vaccine which is stable at room temperature for at least six months unlike the current licenced vaccines. This vaccine could potentially be used in regions where storing and transporting vaccines at low temperature is difficult^[234].

Further vaccine development (including mRNA vaccines, which produce the most potent responses), development of multivalent or pan-coronavirus agents, treatment and vaccine clinical trials, especially in those who are immunosuppressed will all form part of the future of vaccination.

6.5 Treatments

When the pandemic spread across Scotland and the UK from March 2020, no effective therapies for SARS-CoV-2 were available to clinicians. Rapidly, however, large scale clinical trials have allowed us to have a sound evidence base to introduce effective therapies that have been shown to be effective. There are broadly two classes of therapies that have been developed: those targeting the virus itself (antiviral therapy), and those targeting the host inflammatory response (anti-inflammatory therapy). Resistance to antiviral drugs can occur when mutations spontaneously arise and give the mutated virus a survival advantage in the presence of an antiviral drug^[235]. The Therapeutics Taskforce is responsible for the provision of treatments for COVID-19 in the UK^{[236] [237]}.

The regularly used existing anti-inflammatory steroid called dexamethasone was successful in clinical trials at reducing Covid related death (in specific sets of patients) and days spent in hospital^[238]. It was rapidly included in treatment for hospitalised patients requiring oxygen for COVID-19 and as it targets the host response it is not affected by any of the different variants of SARS-CoV-2 that have emerged and remains a standard of care.

Another anti-inflammatory therapy is the use of antibodies targeting Interleukin-6 (IL-6). Two of these therapies called tocilizumab and sarilumab have shown benefits in clinical trials in intensive care patients with COVID-19, and those in hospital requiring oxygen support^[239]. They are now used as standard of care for patients with COVID-19 who have clear evidence of an inflammatory response and a need for oxygen therapy. As they target the host response to infection, their effects are not altered with infection from different SARS-CoV-2 variants.

Other potential anti-inflammatory therapies have been tested in trials or are under evaluation. At the current time, none of these are licensed for use for COVID-19 in the UK. However, there are promising preliminary results for several agents. For example, a drug directly targeting inflammatory pathways called baricitinib has been shown to have potential benefit and further trial evidence will establish its role in the future^[240].

Remdesivir is an antiviral drug originally developed for the treatment of hepatitis C, and as a potential treatment for viral hemorrhagic fevers such as Ebola virus disease. A number of trials of Remdesivir for the treatment of COVID-19 have been carried out^{[241] [242]}. The current UK wide interim commissioning policy recommends its use as one possible therapy for community treatment of patients within 7 days of onset with COVID-19 who have a pre-specified risk factor for possible progression to severe disease^[243]. It is also an option in the treatment of such high-risk patients who acquire COVID-19 while in hospital and not requiring supplemental oxygen^[244] as well as patients admitted with COVID-19 who are receiving oxygen therapy^[245]. There is no resistance to Remdesivir yet reported, but as with any antimicrobial agent, this may well arise in the future.

Molnupirivir is a directly acting oral antiviral drug that inhibits SARS-CoV-2 replication. The current UK commissioning policy on the use of Molnupirivir is to recommend its potential use in non-hospitalised patients within 5 days of onset of symptomatic COVID-19 who are at risk of progression to severe disease^[246]. However, it is designated as a third-line treatment with Paxlovid as first line, and Remdesivir as second line. As with any anti-microbial, there is a risk of drug resistance developing, although this has not yet been detected.

Paxlovid (nirmatrelvir plus ritonavir) prevents SARS-CoV-2 replication and the drug targets a protein that does not show significant variation in SARS-CoV-2 variants so far described. The current UK commissioning policy on the use of Paxlovid is as a first line therapy in the treatment of non-hospitalised patients within 5 days of symptom onset who are at risk of progression of disease^[247]. It is also a first-line therapy for consideration in treating patients with hospital-onset COVID-19 at risk of progression to severe disease^[248]. Again, as with all of these antiviral therapies, emergence of resistance remains a risk although not yet currently seen with Paxlovid.

Monoclonal antibodies are artificial laboratory synthesised antibodies that target the SARS-CoV-2 virus. The currently used antibodies bind extremely tightly to the viral ‘spike’ protein which is essential for virus entry into cells. Hence, they neutralise viral action and thus abrogate the effects of the infection. Ronapreve is a combination of 2 antibodies, however, it has no activity against the omicron variant of SARS-CoV-2, which is now completely dominant in Scotland. Hence, it effectively has become redundant although it might retain activity against future variants. Sotrovimab is another antibody directed against the SARS-CoV-2 spike protein, with different specificity to Ronapreve. It retains activity against the omicron variant. A number of trials have shown that it of benefit in treating patients early in the course of infection^[249]. Future variants may not be neutralised by Sotrovimab, but its target is an evolutionarily conserved part of the spike protein that is not directly in the receptor binding domain of the protein and so far retains good activity against all variants of SARS-CoV-2. A number of other monoclonal antibody therapies have been developed and trials of these agents in patients with COVID-19 are underway.

The development of the therapies together with vaccination have greatly improved the outcomes of patients who develop COVID-19. Many more therapies have been developed and are undergoing investigation^{[250] [251]}. Importantly, we will need to know what additional benefit every therapy gives in those who have been vaccinated and in the context of the clinical severity of a particular variant – currently omicron produces a milder disease with less risk of hospitalisation or death in a vaccinated population. However, this may not necessarily be the case for any future variant that arises, so the range of treatments currently available remain important.

6.6 The efficacy of different interventions

Scotland, like other nations, responded to the pandemic in a number of ways to reduce the number of infections, hospitalisations and deaths at the peak of the infection waves. The measures put in place have varied from total lockdown in the first wave to the current restrictions of face covering mandates, COVID-19 vaccine certification in specific settings or testing and checks for international travellers.

The vaccine certification scheme for Scotland was announced on 1 September, 2021 and became enforceable in law on 18 October, 2021. Proof of evidence of vaccination status came into effect for higher risk settings:

• Late night venues open after midnight with alcohol, music and dancing;
• Live indoor unseated events of 500 or more people;
• Live outdoor unseated events of 4,000 or more people; and
• Any event of 10,000 or more people.

The scope of the certification scheme in Scotland was narrower than most comparator countries. The certification scheme was modified on 6 December, 2021 to allow individuals to provide proof of a negative COVID-19 test within the previous 24 hours as an alternative to vaccination. The scheme was further amended on 17 January, 2022 to add the requirement that a booster/third dose was necessary to be considered fully vaccinated in response to the immune escape properties of the Omicron variant.

The aims of the vaccine certification scheme were to:

• Reduce the risk of transmission of Coronavirus;
• Reduce the risk of serious illness and death thereby alleviating current and future pressure on the National Health Service;
• Reduce the risk of settings specified in the scheme being required to operate under more restrictive protections, or to close;
• Increase the protection enjoyed by those using settings covered by the scheme and their contacts.

The Scottish Government published two evidence papers covering vaccine certification^{[252] [253]}, however, little published evidence exists on the overall effectiveness of vaccination schemes in terms of increasing vaccine uptake or to reduce transmission rates.

One study looking at the impact of certification schemes in France, Germany and Italy, based on counterfactual modelling, suggested that the incentives created by certification increased vaccine uptake by 13% in France, 6.2% in Germany and 9.7% in Italy by the end of 2021. Without the increase in vaccination driven by certification, they estimate hospital admissions (and deaths) would have been 31.3% (31.7%) higher in France, 5.0% (5.6%) higher in Germany, and 15.5% (14.0%) higher in Italy in the period between their introduction and the end of 2021. The researchers also state that in terms of economic impact, the absence of certificates and resulting lower levels of vaccination would have resulted in estimated losses of €6bn in France, €1.4bn in Germany and €2.1bn in Italy by the end of 2021^[254].

Direct comparisons to the success (or otherwise) of the certification scheme within Scotland cannot be made as certificates were introduced later in the pandemic in Scotland (October) compared to France, Germany and Italy (July and August). Vaccinations levels were much higher in Scotland at the time of the announcement of the certification scheme compared to when the schemes were announced in France, Germany and Italy, thereby reducing the overall impact of vaccine certification in Scotland. Indeed, comparison of vaccination rates across the 4 UK nations suggests that there was a minor impact on vaccine uptake when the certification scheme was announced in Scotland. At that time, the rate of overall increase in first and second doses was similar across all 4 UK nations, however, they were all starting from an already high level of vaccination uptake and coverage.

Several countries including Denmark and Ireland have already abolished their certification schemes.

The general expert view is restrictions or packages of measures are most effective in combination. It is difficult to estimate the effectiveness of each individual intervention or measure on reducing transmission, however, vaccines are the best tool we have to reduce severe disease, death and transmission in the population ^{[255] [256] [257] [258] [259]}. Physical distancing is also an established way of reducing transmission of viruses, including SARS-CoV-2^{[260] [261] [262]}.

A study estimated the effectiveness of 17 non-pharmaceutical interventions in Europe’s second wave and found that business closures, educational institution closures, and gathering bans during the second wave reduced transmission, but the reduction was smaller than in the first wave. They found smaller effects for closing educational institutions in the second wave possibly due to the safety measures put in place during the second wave which made schools safer compared to the first wave^[263]. Recent expert opinions are that the harms caused by closing schools during a peak in infections, outweigh possible benefits of any reduction in transmission this may bring, and that school closure should be considered only as a last resort^[264].

The UK expert group SPI-B found that there was no sign of decline in effectiveness of interventions when they were reintroduced for a second or third time^[265]. The effectiveness of introducing individual interventions or packages of non-pharmaceutical intervention (NPI) measures will depend on the epidemiological context in which measures are introduced, baseline public behaviours in place at the time of the implementation and public adherence to NPIs^[266].

In Autumn 2021 when cases were high, but before the start of the Omicron wave, SPI-B, SPI-M and EMG advised that reintroduction of working from home (WFH) guidance may have the largest impact on transmission in England out of the ‘Plan B’ measures (which also were wearing of face coverings in specific settings and introduction of certification schemes) proposed by UK Government^[267]. They also advised that vaccine-only certification may only have a very small direct impact on transmission. Increasing the range of settings, time-limiting certificates based on last vaccination date, and including proof of a negative test, could increase the potential impact on transmission^[268]. They considered other measures that would have a lasting impact are regular asymptomatic rapid antigen testing at the workplace, improved ventilation in schools and workplaces and improved public awareness of the requirement to take a test if symptomatic^[269].

In the event of a rapid increase in infections, Juniper (Joint Universities Pandemic and Epidemiological Research) consortium advised that in addition to vaccination certification, face coverings in specific settings and working from home were additional measures that should be considered. Some measures would take longer to implement but would have a lasting impact (listed first), while others are more immediate (but less sustainable) and are listed last.

1. Improved ventilation in schools and workplaces

2. Improved public awareness of hospital capacity status including non COVID pressure

3. Boosters and increased vaccine uptake

4. Test, Trace and Isolate (TTI) (Test and Protect in Scotland)

5. Changes to restrictions and potential lockdowns

6. Antivirals and pharmaceuticals.

7. Travel restrictions ^[270]

A UKHSA rapid review on the effectiveness of face coverings published in November 2021 suggests that face coverings reduce the spread of COVID-19 in the community^[271]. There are preliminary findings from a Department for Education study indicating face coverings may have a potential positive effect in reducing pupil absence. However, there is a high level of statistical uncertainty and the study is yet to be peer reviewed. The benefits of face masks in reducing transmission need to be balanced with the drawbacks, for example, there is evidence from previous studies that pupils find communication and learning more difficult when wearing face coverings^[272].

Outcomes are worse for older age groups and some clinical vulnerable people when infected with SARS-CoV-2 and measures to minimise transmission are even more important to protect these cohorts^[273].

6.7 Public attitudes and expectations

Polling has shown the Scottish public taking a cautious approach throughout the pandemic, with sustained high levels of adherence to the Coronavirus rules and regulations, and a continued belief in the importance of the protective measures that have been in place to manage the spread of Coronavirus^[274]. However there have been practical and emotional barriers for some that have affected their ability to adhere to restrictions. This includes, for instance, people’s living arrangements, caring responsibilities, availability of food, finances, and health conditions^[275].

As the pandemic continues, and following the emergence of the Omicron variant, there are signs that people expect control measures will need to continue.

Polling on restrictions in January 2022 found that 53% of Scottish respondents supported removing some restrictions but not others, with only 17% in favour of removing all of the restrictions and 24% in favour of keeping them all^[276].

People are supportive of, and expect to live with some protective behaviours, with 76% agreeing they are happy to follow some rules and guidance if it means they can do the things that matter to them, and 75% agreeing they have a responsibility to follow the rules and guidance from the Scottish Government to keep others safe^[277]. Polling suggests the majority of Britons (91%) continue to feel a face covering is important in slowing the spread of COVID-19, alongside booster vaccines (89%) and social distancing (87%)^[278].

In Scotland based polling, the behaviours most likely to be considered sensible to still be doing in April/May of this year are respiratory and hand hygiene-related behaviours (e.g. washing/sanitising hands (72%), and covering mouth when coughing (75%) and wearing face coverings in shops/on public transport (68%). Around two thirds (64%) mention keeping up with Covid vaccinations, with slightly smaller proportions citing following self-isolation rules (60%) and using LFD tests (54%). Meeting up with restricted numbers of friends is least likely to be mentioned, at 33%^[279].

6.8 Persistent inequalities

Throughout this paper inequalities have been identified. Many of the factors that contribute to these inequalities have been brought together in an analysis of enduring transmission. Enduring transmission can be defined as an area of early increasing prevalence and/or slower decline in prevalence^[280], compared to the national average, despite highly restrictive non-pharmaceutical interventions. The drivers are multifaceted and can be both static (population density) or dynamic (public health intervention).

Data relating to elevated rates of cases, compared to the national average, can be considered against demographic and deprivation data to review the potential role of social and economic factors in sustained local transmission. The patterning of areas of enduring transmission observed in Scotland are not explained by socioeconomic deprivation alone. Other drivers of high case rates are likely to be contributing factors to sustained transmission in these areas and are the subject of ongoing research.

Figure 29 below shows how cases, booster coverage and deaths have varied across the country along with a visual showing the distribution of datazones.

6.9 International experiences

6.9.1 Lifted restrictions

Denmark lifted its COVID-19 restrictions on 1 February, 2022, declaring that COVID-19 no longer qualifies as a critical threat^[284]. This included ending COVID-19 certification, working from home and facemasks. Recommendations remain for testing and the use of protective measures (certification, face coverings etc.) in high risk areas, such as at hospitals^[285]. Both Sweden and Norway have lifted most remaining COVID-19 restrictions, including on social distancing and indoor events^{[286] [287]} and the Dutch government announced that it will lift the majority of COVID-19 restrictions by 25 February^[288].

Ireland lifted most restrictions on 22 January 2022, including certification, social distancing, event capacity restrictions and night clubs reopening. From the 24 January, a phased return to offices began. Remaining restrictions including face coverings, self-isolation and protective measures in school are due to reviewed on 28 February^[289].

The Prime Minister announced on 9 February, 2022, that the UK Government may lift all domestic regulations a month ahead of their original schedule of 24 March, should data remain supportive^[290].

Northern Ireland lifted all remaining COVID-19 restrictions on 15 February 2022, announcing that the remaining measures are going to be put in guidance issued to the general public. The use of COVID-19 certificates in nightclubs, face coverings, track and trace requirements and the cap on 30 people allowed in private homes were all removed from law. Guidance on working from home where possible have not been changed^[291].

The Welsh Assembly announced the outcomes from the latest review of their coronavirus regulations (10 February, 2022) on 11 February. They stated that their domestic COVID Pass will no longer be required from 18 February, however, this does not impact international travel requirements. From 28 February, face coverings will only be required in shops, on public transport and health and care settings, with an expectation that the legal requirement to wear face coverings will end across all settings by end of March, 2022. They also announced that the requirement for wearing a face covering upon return to schools will be made at local levels (through local guidance framework)^[292].

6.9.2 Levels approach to Covid regulation

Chile, Italy and Israel have adopted a levels approach, with regions being allocated a level based on case numbers which determines their level of openness. Chile has 5 levels (Restriction, Transition, Preparation, Initial Opening, and Advanced Aperture) with the majority currently in either Transition or Preparation^[293]. Italy has three levels (white, yellow and orange) with the majority in yellow^[294] and Israel has a 4 level traffic light approach with red indicating a restraining policy (e.g. lockdowns); orange prevention policies (e.g. high risk closures); yellow a cautious reopening and green a return to normal^[295]. The majority of Israel’s local councils are currently in red (but not at the strictest form of a lockdown).

South Africa and Australia have a national level plan for emerging from the COVID-19 pandemic. South Africa range from levels 1 to 4 (4 being most restrictive) and are currently in an adjusted version of level 1. Australia have laid out a 4 part plan for reopening based on vaccination levels and are currently in Phase D; a ‘Post-Vaccination Phase’ of re-opening^[296].

The Norwegian government are currently updating their infection control measure guidance and are due to publish in spring a revised pandemic management strategy and emergency preparedness plan^[297].

A range of current restrictions have been collated for comparator countries; Australia (New South Wales)^[298], Austria^[299], Belgium^[300], Canada (Ontario)^[301], Chile (level 3 region)^[302], France^[303], Germany^[304] (Berlin)^[305], Israel (Red region)^[306], Netherlands^[307], Norway^[308], Singapore^{[309] [310]}, South Africa^[311] and the USA (California)^[312].

Daily tests per 1000 people vary but across the majority of comparators, testing has decreased since January echoing the shift to treat COVID-19 as an endemic disease, see Figure 30^[313].

Source: Coronavirus (COVID-19) Testing - Our World in Data, Accessed 16 February 2022.

Facemasks are mandatory indoors and on public transport in the majority of comparator countries, with Singapore also requiring them outdoors. Germany and Austria specify that mask must be of a FFP2 standard.

A version of certification used for events, indoor hospitality and indoor leisure facilities, is widely used in comparator countries, with Singapore, Canada (Ontario) and Australia (New South Wales) only accepting proof of vaccination. In Norway, the use of certification is governed by local municipalities^[314] and in Germany (Berlin), a 2G+ model (vaccination or recovery plus testing) is required for certain events, indoor hospitality and leisure unless booster vaccinated.

Most comparator countries encourage a work from home option where possible, with Belgium only allowing one day a week in work, Singapore at 50% reoccupation and Germany (Berlin) only allow people in work if it cannot be done from home. Austria and Germany (Berlin) require proof of vaccination, testing or recovery with Singapore requiring proof of vaccination or recovery. In Canada (Ontario), you must answer screening questions (including recent travel, vaccination status and symptoms) before attending work. The majority of comparators that allow a return to offices require staff to wear face coverings and/or implement social distancing.

The majority of comparators have capacity restrictions on events and indoor spaces, ranging from 25 in Canada (Ontario) to 2000 in Germany (Berlin). Nightclubs are shut or activities restricted in just under half of the comparators. Private gatherings are restricted in the Netherlands, Singapore and Germany (Berlin). In the Netherlands, you can meet 4 people from one household a day; in Singapore it’s restricted to 5 vaccinated people from different households a day and in Germany (Berlin) unvaccinated individuals are restricted to 2 people from one other household per day.

All comparator countries have reopened face to face teaching with the majority requiring face coverings and antigen testing. In Germany (Berlin), the decision remains with the parents if they want their children to attend school in person. In France, Baccalaureate speciality exams have been delayed from March to May 2022.

The minority of comparator countries have made vaccination mandatory, primarily seen for healthcare and education workers^{[315] [316]}. In Italy, vaccination is mandatory for anyone over 50 years and in Austria anyone over the age of 18^{[317] [318]}.

6.9.3 International perspectives on the future.

The World Health Organisation (WHO) and the United Nations (UN) have made recommendations on how to recover from the pandemic. Early on in the pandemic the WHO made a manifesto of recovery focusing on improving the environment and investing in essential services^[319]. The UN focuses on 5 pillars of recovery Research Roadmap for COVID-19 Recovery (health systems and services; social protection and basic services; economic response and recovery programs; macroeconomic policies and multilateral collaboration; and social cohesion and community resilience)^[320]. The UN Research Roadmap aims to better equip researchers, research funding agencies, Governments, UN entities and other international institutions to harness and share collective knowledge and innovation in order to catalyse transformative changes and achieve the Sustainable Development Goals (SDGs).

The European Union (EU), have developed a Recovery and Resilience Facility to help the EU emerge stronger and more resilient from the current crisis. It is helping to fund the recovery of Member States from the pandemic and their resilience to cope with future ones^[321]. The main focus for investment is on climate neutrality and digital transitions with Member States being allocated almost 40% of spending to climate and 26% on digital improvements. Many EU countries have allocated investment to the development and improvement of their health care systems including the construction of the Northern Estonia Medical Campus, 5 new centres of expertise in infectious diseases in Lithuania and upgrades to the Clinic for Infectious Disease in Ljubljana, Slovenia. Full details of plans can be found here. In Germany, the newly launched Centre for Pandemic Vaccines and Therapeutics works towards building infrastructure to provide safe and efficient vaccines and therapeutics as quickly as possible in the event of a pandemic^[322]. In France, the development of the EMERGEN consortium is improving sequencing capacity for COVID-19 and other diseases^[323].

Outside of the EU, Canada announced it is establishing a Centre for Research on Pandemic Preparedness and Health Emergencies working to develop research for pandemic and health emergency preparedness, prevention, response, and recovery that contributes meaningfully to timely, equitable and effective responses and recovery^[324]. In the USA, the Biden-Harris administration have announced a Government wide review and update of the US national bio-preparedness policies, focusing on improving medical defences, ensuring situational awareness, strengthening public health systems and developing core capability^[325]. In addition, the US National Centre for Epidemic Forecasting and Outbreak Analytics has been created^[326].

Ensuring that lessons are learnt is included in the majority of recovery and preparedness schemes, such as Italy’s “PanFlu”^[327]. The OECD recommends further investigation into the effectives of lockdowns and other restrictions due to the impact on individual liberties, domestic violence, alcohol consumption, and mental health^[328].

The idea of ‘living with COVID-19’ is now being debated in several countries, including Italy, the Netherlands, New Zealand and Spain, however, only Denmark and South Korea have set out comprehensive strategies for what 'living with COVID-19' will look like throughout 2022.

Denmark has created a three-phased strategy that includes the administration of an additional booster dose (i.e. fourth overall) for the most vulnerable, scaling back free antigen testing but encouraging people to conduct self-funded testing throughout the spring. They also plan to monitor COVID-19 through waste water testing and sequence analysis during spring and summer and may consider additional vaccination and the return of some NPI measures during autumn and winter^[329]. South Korea published a ‘2022 Joint Action Plans for fight against Covid-19’. The two main objectives are to bring a timely recovery to the current crisis and a gradual movement to a new normal, and establish the foundation for “living with COVID-19” by building a sustainable disease control and prevention system^[330]. The plan promotes vaccination and boosters; expansion of antiviral treatments; 'revamp' of NPIs toward more targeted measures; increase in financial support for (vaccinated or recovered) self-isolators; and expansion of contact-tracing and genomic surveillance.

6.10 Summary

Looking forward, the ability to manage the pandemic has changed significantly over the past two years. A better understanding of the science of the pandemic, the emergence of variants, the range of effective vaccines available, the development of new treatments and the efficacy of different interventions all contribute to a new range of tools to manage the pandemic in the future. Public understanding has developed, and the importance of monitored public attitudes has been highlighted. However there are areas of persistent inequality that have emerged and will need to be researched and addressed. Finally, Scotland is not alone in tackling the pandemic and can continue to learn from the experiences of other countries in the future.