Scottish Government COVID-19 Advisory Group minutes: 16 July 2020

Attendees and apologies

Attendees

• Andrew Morris
• Harry Burns
• Tom Evans
• Roger Halliday
• Jim McMenamin
• Jill Pell
• Steve Reicher
• Jacqui Reilly
• Chris Robertson
• Sheila Rowan
• Aziz Sheikh
• Devi Sridhar
• Nicola Steedman
• Mark Woolhouse

Invited attendees

• Mary Black

Scottish Government

• [Redacted]
• Daniel Kleinberg
• [Redacted]
• Niamh O’Connor
• [Redacted]

Secretariat

• [Redacted]

Items and actions

Welcome and apologies

The Chair welcomed group members and observers attending today: [Redacted].

Apologies – [Redacted].

Minutes and actions

All group members were content with the minutes from the previous week.

Co-infection was briefly discussed, looking at the available evidence of what might happen if there is co-circulation of influenza and COVID-19. This had been considered by the New and Emerging Respiratory Virus Threats Advisory Group (NERVTAG). Point-of-care testing and multiplex PCR testing for a variety of pathogens would be highly beneficial. Co-circulation could place significant pressure on intensive therapy units.

The importance of maximizing influenza vaccination uptake for high risk groups was stressed by group members. Plans are being considered to extend influenza vaccination to additional high risk groups, alongside planning for a possible COVID-19 vaccination programme.

Group members noted current patterns of seasonal influenza in the southern hemisphere could mean the projections of the Academy of Medical Sciences report are closer to a worst-case scenario. It is hoped that COVID-19 mitigation measures will also limit influenza transmission.

Regarding community transmission – group members noted that we are now in a phase of sporadic community transmission. Most NHS boards are reporting 0 cases over several days, with single cases then occurring. Where positive cases do occur these are not necessarily linked, reinforcing the need for caution. Funding has been obtained for additional genetic analysis which can determine whether cases are from the same strain. There is work needed to understand how best to respond to additional new cases where numbers are as low as they are currently.

There is a good level of confidence in current modelling. In England, active case-finding is finding a high proportion of asymptomatic cases.

The Chair noted a possible deep-dive next week and the participation of Prof John Bell at next week’s meeting.

Action: English SitRep will be circulated by the Chair. Scottish SitRep are posted in the group’s Objective Connect folder.

Action: [Redacted] to update the group on modelling initiatives by the end of September.

Action: [Redacted] to share co-infection paper with the Public Health Threat Assessment subgroup.

Action: group to be sighted on active surveillance paper that went to Cabinet.

Action: [Redacted] to circulate additional Public Health Scotland materials for group members. 

Testing strategy

The Chair thanked group members for their contributions to material for today’s discussion.

It was noted that the testing subgroup paper had informed the development of the Testing Strategy. Case-finding is the greatest interest of the strategy, testing contacts of indexed cases to find new cases early. This is an approach to mitigate having to go back into lockdown.

The structure of the Testing Strategy is in place. The text highlights that testing is an essential part of an overall response but not a silver bullet. Group members noted that the Testing Strategy will need to be flexible, though there are clear difficulties should the indication for testing one group be stopped to allow testing of another. Clear communication will remain important.

Group members discussed possible alternative testing provision. Examples of this included: using testing to allow physical contact with those in care homes; testing on demand (e.g. for those in contact with vulnerable individuals – without blanket testing); screening of all those entering a hospital, or requiring aerosol-generating dental treatment; testing all those in a workplace where a case has been detected.

Group members noted a current discrepancy whereby testing is offered to care home workers but not domiciliary care workers.

False positives – these pose a challenge for clinicians, particularly for those patients urgently requiring care. Double testing can help to reduce the risk of these. There is also the risk that entire services may have to shut if a large number of false positives are detected, further impacting on care. An agreed protocol is needed for false positive tests.

Testing of health care workers (HCW) – the nosocomial group did not recommend blanket testing of HCW but rather focussing on focussed testing where a case is detected. In England testing is in theory offered to all HCW, with priority given to symptomatic and potential asymptomatic cases. All healthcare workers and patients are being tested on admission. This is not currently the case in Scotland and Wales.

Scotland is currently involved in the SIREN study.

Public Health England has done some modelling, looking at potentially testing all those coming out of hospitals, to try to reduce transmission rates. Data showed this would reduce transmission but issue remains of delaying discharge where patients wait for a further test and the risk of higher levels of infection from so-called ‘amber’ wards where they could remain while awaiting a test.

Group members stressed that testing should be viewed as one component of a public health intervention. Important that testing is used in conjunction with other public health measures that are helpful as part of overall public health response and the work of public health teams. The difference between testing and screening was noted, with group members commenting that these are often mistakenly used interchangeably.

Challenges that have been raised are currently being looked at – at what different level of prevalence do you get the best out of each testing strategy. Group members noted an upcoming publication from the National Institute for Health and Care Excellence on this.

There were suggestions that a four harms perspective should be used when determining criteria for testing. Issues already identified should be woven into every consideration – e.g. BAME risk. There are known issues from polling data in England, of those requiring tests being unable or unwilling to get tested.

ECDC and CDC starting to publish guidance on use of testing capacity which group members will consider when drawing together an composite addendum on testing.

The Chair reiterated that the role of group is not to write policy, but highlight the evidence based that should be used by those formulating policy.

Action: Group to put together composite addendum of current consideration of the science, as a follow-up from the subgroup’s testing paper. [Redacted] to lead on this, with group sending contributions.

Action: [Redacted] to discuss with [Redacted] the possibility of publishing testing addendum in parallel with release of the testing strategy.

Care homes, respite care and day care advice

Key question: is it safe to proceed to stage 3 (visiting on 24th July).

Position – recognising the ever present threat and need for care homes to monitor situation in community. Criteria proposed within paper are broadly acceptable and in-line with work group members had done on the criteria for indoor visiting.

One inconsistency: period between starting visiting outdoors and moving on to others. Three week period built in, but in other parts of the guidance this is referred to 28 period. Group members agreed this should be three weeks, given the known risk of harm from cognitive decline. Group members suggested that where there may have been issues with adherence to guidelines in the past, additional auditing of care home practices may be needed.

IPC measures - additional considerations needed for understanding of built environment, ventilation and restricting visitor numbers. A risk assessment at care home level should be undertaken to at care home level. 

Work done by NHS Lothian on this subject was highlighted as being highly valuable. Group members noted that granular data on care homes can be difficult to obtain for care homes, for instance on staff, rotas, ratio for size of care homes etc.

Opening care homes is a balance of risk. Given we are in low risk now it would be suitable to move to next phase. Lockdown would need to be reintroduced if there are new positive cases detected in the care home.

Modelling from CogUK group found that there was not one single mechanisms for spreading COVID-19. There were incidents where strains where transmitted from home to home. Current guidance makes reference to avoiding staff movement, though the group recognised that the high number of vacancies in the sector, coupled with the reliance on agency staff may make this difficult.

Group members agreed that the group’s advice would need an addition on visitor testing with respect to a risk assessment. This would be for those with longer time exposure or who are involved in care of residents. With regards to the advice on respite care and day care services, it was noted that many questions were more operational and not directly within the remit of this group.

Group members briefly discussed visors, noting that protection from these is lower compared to wearing a mask.

Action: [Redacted] to update advice on Care Homes in light of discussion and Chair to finalise both pieces of advice before Secretariat send to Ministers.

Subgroup updates

Education papers on distancing and transport have been published. Scotland will have least restrictions on schools returning out of four UK nations. The subgroup’s advice highlights need for flexibility with this, taking into consideration local COVID-19 rates. Implementing distancing is not a low-cost decision, given impact on education for those already disadvantaged. Outbreaks in other countries seem to be happening more in senior schools.

Winter group discussed testing at a time when cough and flu may have same symptoms. Location of testing needs to protect primary care and avoid discouraging patients from seeking care. Christmas period will see higher contact between people in social and retail spaces so prudent to plan for higher transmission of COVID-19 and influenza then, though COVID-19 precautions should also lower flu transmission. Need to increase uptake of flu vaccination, particularly within HCWs.

CSA update

The CSA noted contributions to education subgroup this week.

SAGE update

COVID-19 security – how to create a composite, quantitative measure of COVID-19 risk. More work ongoing. Segmentation – work ongoing but looking at whether we can segment population by age etc. to break transmission. SitRep – prevalence is so low we can’t use R. Singing/wind instruments – being considered by PHE but thesis is that aerosol effect is enhanced. New group being set up on audiences.

Future agenda items

Higher education – for discussion next week. SAGE paper shared on this last week. 

No immediate commissions for advice from Ministers.