Scottish Government COVID-19 Advisory Group minutes: 15 April 2021

Attendees and apologies

Advisory group members

• Andrew Morris
• Dave Caesar
• Tom Evans
• Nick Hopkins
•  Audrey MacDougall
• Jim McMenamin
•  Jill Pell
• Stephen Reicher
• Jacqui Reilly
• Chris Robertson
• Sheila Rowan
• Gregor Smith
• Devi Sridhar
• Carol Tannahill
• Mark Woolhouse

Invited attendees

• Cat Carver
• Gabe Docherty

SG

• Daniel Kleinberg 
• [REDACTED]
• Arlene Reynolds
• Elizabeth Sadler

Secretariat 

• [REDACTED]

Items and actions

Welcome

The Chair welcomed group members and SG observers attending, noting that it was the 48th meeting of the advisory group and thanking group members for their contribution over the past year.

CMO noted that the data over the past 10 days had been better, though the future remained unclear and we need to consider different scenarios. As part of that we can learn from global data, which is now showing the impact of the Kent variant elsewhere. That reinforces the need to learn from previous waves and get case numbers as low as possible to reduce the risk of harm from further variants arising, which might undermine the vaccination campaign. We need to look at what is happening in South America – Argentina, Uruguay and Brazil as well as Chile and look at the impacts of different vaccines and approaches.

Minutes

The minutes of the previous meeting will be shared with group members for written comments. 

Lessons learned – Israel and Chile

Our thinking on the way forward in responding to the pandemic can be informed by experience elsewhere on - how to lift restrictions; how much will vaccines do the heavy lifting; can border controls control variants; what’s the impact of seasonality.

While there may be a seasonality effect, it doesn’t appear to be strong – the hot weather in South America doesn’t appear to be helping. Chile has undertaken lots of vaccination but little impact so far - the CoronaVac vaccine may be less effective and Chile may have eased domestic restrictions too soon. There has been a similar experience in Uruguay. In contrast, Israel is doing well – heading to low cases and appears to be benefitting from undertaking lots of vaccinations, primarily using Pfizer.

Both Chile and Israel have harsh border policies plus additional measures in place - Chile has now implemented a very strict lockdown and Israel has maintained a number of NPIs e.g. requirements re face coverings and a green pass system to access bars and other activities.

In discussion, it was noted that reaching a judgement on the impact of seasonality is difficult. It is not much fed into models as it is difficult to predict the impact for a new virus. Experience will develop and, while COVID-19 transmission appears to be greater in winter conditions, there are significant uncertainties about impact of seasonality on behaviour.

We need to consider how we strike the right balance between lifting restrictions and vaccination? International comparisons are helpful but there is a need to articulate the complexity – learning is not always easily transferable. We can learn from elsewhere but always need to be conscious that the cultural context is very different e.g. Israel’s green card system. While it has been suggested that green cards have encouraged vaccine uptake there’s currently no evidence of that, though there are indications of good examples of community outreach. In the US, vaccination acts as a ticket to meet unmasked indoors 3 weeks after vaccination. US had one of the lowest vaccine acceptance rates but now quite high – these rewards are probably a factor in that. In all these cases there are questions of behavioural impacts and fairness. In terms of international travel, it appeared that we would be opening ahead of Israel, although we are behind them on vaccinations.

WHO’s Special Envoy on COVID-19, David Nabarro, suggested recently that the pandemic will be with us for years and questioned whether we could vaccinate ourselves out of it. Some NPIs may never change, particularly in healthcare – there appear to be benefits for the prevention of other infections. Israel’s experience and our progress with vaccination suggests that success through vaccination may be possible for individual countries but problems will remain until there is a global solution.

It was suggested that what we do in April won’t be the most important impact on the autumn, which will also be affected by progress with vaccination and actions nearer the time. There are a number of externalities – including variants, seasonality and behaviour – that mean we can’t simply extrapolate from now to then. It was observed that Israel’s strict border restrictions hadn’t stopped the Kent variant being imported. Even if border controls are in place there remains a risk of importation of new variants. The Brazil & South Africa variants are in the UK – currently at very low numbers but we need a plan to stop them growing, and to respond if they do.

The contrary view was that actions now are important. While decisions now can’t end the pandemic, they can reduce risk, limit harm and avoid making it worse. The speed of reopening could amplify problems so decisions now are significant. There is no guarantee that measures such as NPIs and travel restrictions will prevent future waves but the time gained by delaying any future wave should be used to ensure the country is prepared to respond to the challenges these present. We cannot rely solely on vaccination – there are multiple layers of protection and vaccination is only one.

We need to limit potential harm to our population, including from the introduction of variants. Delay is a credible strategy to help achieve that. We can’t prevent international travel forever but when is risk at the right level to permit? More time enables more vaccination and also aids our understanding of variants and how to address them, whether via test and protect, surge testing or ring vaccination or the London borough approach.

While we should be cautious about the autumn, we are in a good position compared to last year as the latest restrictions have given us time to vaccinate and think about how we should react to variants. In a year, everyone will have some level of immunity but may need a booster to respond to variants.

The pandemic is not over but the messaging is important. People need hope and we can be positive about the progress we have made and the tools we now have. The systems we have in place will allow us to monitor effectiveness of vaccines but we are not able to work in isolation – decisions elsewhere impact on Scotland and vice-versa.

We need to consider the impact on behaviour as we lift restrictions. It will depend on the messaging and whether it says our behaviours are effective as efficacy is a key determinant of behaviour. However, a danger of opening up is a perception of less risk, which is another key determinant of behaviour. WHO refer to this up as the dangers of complacency and confusion. Messaging till now has been more about rules and less about principles of understanding risk and behaviour – need to work on communicating risk. Work is being done on this by SPI-B. People want to see progress but need to understand what we do now affects what we do in future. The Swiss cheese model of multiple layers of protection could be an effective way of communicating that message.

Concluding the discussion the chair noted that the effect of seasonality is uncertain and getting to August/September in a good place is multifactorial. Decisions elsewhere in Europe will affect Scotland and stopping variants will be hard – we need a plan B using surge testing etc. It will be key for messaging to focus on principles rather than rules – cross-cultural comparisons will be important – vaccine efficacy is not binary.

State of the pandemic

The group referred to the papers circulated for this item. It was encouraging to see reduced cases and that previous concerns about younger age groups and spread in community haven’t transpired. It was important to be looking at new VOC. The Kent variant had continued to account for 80-90% of cases, with day-to-day variability and there is a need to watch for any significant changes involving other VOC/VOIs. Glasgow Lighthouse’s capabilities are a valuable resource in this context – the capacity to put large numbers of sample through genomic testing locally reduces delays.

There was discussion of how best to measure progression of the epidemic as it develops. As incidence reduces and testing capacity increases some measures become less useful or reliable and local/surge testing can present difficulties in making comparisons between local areas’ data. It was therefore important to look at other ways of measuring what’s happening across the country e.g. waste water testing and the ONS infection survey. The aim is to achieve the most reliable basket of measures in a situation where testing practices and extent are changing – are we/do we need to be measuring something slightly different than before?

It is important to recognise the danger of misinterpreting the data – as testing goes up the positivity percentage becomes less meaningful. A large proportion of cases are now asymptomatic and ONS data may be the best indicator, though it is based on limited numbers in Scotland and only covers the community and not healthcare or workplace settings. While we could just monitor hospitalisation, that’s a lag indicator and cases in vulnerable groups, reinfections and variants are all important – sequencing is vital to understanding developments which are not apparent from the headline figure of cases. Important also to recognise that, alongside any concerns about reliability of measurement, there are benefits arising from finding more cases so we have a greater chance of breaking chains of transmission – seeing more of the iceberg is a positive for case finding.

SAGE update 

The chair reported on the latest meeting of SAGE.

Subgroup updates

The Education & children subgroup had concluded that there was nothing in the data to prevent return and schools will be back after Easter. This was supported by the Education Recovery Group. The following meeting would look at wider consequences.

The Nosocomial subgroup noted that we had now passed 1 million LFD tests and had added risk assessment to healthcare guidelines on ventilation, noting that there was insufficient evidence to support the view that airborne transmission was most important. The next meeting will look at future pandemic planning.

AOB

The next meeting of the group will be 13 May, unless there is a need for urgent advice in the interim.