Scottish Government COVID-19 Advisory Group minutes: 18 June 2020

 

Attendees and apologies

Advisory group members

• Andrew Morris

• David Crossman

• Chris Robertson

• Aziz Sheikh

• Devi Sridhar

• Tom Evans

• Stephen Reicher

• Jacqui Reilly

• Mark Woolhouse

• Harry Burns

• Jill Pell

• Sheila Rowan

• Nicola Steedman

• Marion Bain

• Roger Halliday

Scottish Government

• Niamh O’Connor
• Richard Foggo
• Daniel Kleinberg

Secretariat

• [Redacted]

Items and actions

• minutes

• summary notes

Minutes

Welcome and apologies

The Chair welcomed Sir Harry Burns, who will chair the Public Health Threat Assessment sub-group of the Scottish Government COVID-19 Advisory Group. Daniel Kleinberg was welcomed as the new senior Scottish Government lead for the C-19 Advisory Group, as well as [Redacted], who will lead the Secretariat support. It was also announced that, Carol Tannahill, the Scottish Government’s Chief Social Policy Advisory will be joining the advisory group in her role as Chair of the COVID-19 Advisory Sub-Group on Education & Children’s Issues.

Apologies – Angela Leitch, Andrew Morris joining late.

Minutes and actions

All group members were content with minutes. Acknowledged that work was ongoing to respond to the First Minister’s questions.

Action: Secretariat to note on SLACK the point from the First Minister’s response where an earlier response would be helpful.

IPC indicators In care homes

There were a number of IPC control measures introduced at peak that may need revisiting. The group will discuss whether these need changing and what warning systems need to be in place.

Analysis of the RAPID dataset was presented, showing patient movement from hospital to care homes and positive tests relating to this. The RAPID dataset is not a curated dataset, but a dataset used for administrative purposes. Admission date and where a person is admitted from will be included in the dataset. Data showed that the majority of those who had tested positive within 14 days of discharge went into their own homes or other hospital rather than care homes. Group members acknowledged that positives tests 14 days after discharge could mean infections were acquired in the community.

Measures taken in care homes currently include transmission based precautions including the use of masks, visors and gloves for care home workers. Routine testing of residents and staff, including asymptomatic screening is ongoing. Group members noted they had not seen any detailed data on the uptake of these measures. All additional measures need consideration as well as an exit strategy. Preparedness is needed in case measures need to be ramped up again in the future.

Further data is needed for this group to provide advice about the way in which restrictions may be able to ease off.

Serology tests in care homes – This was not discussed by SAGE today. The group discussed data from the VIVALDI study relating to this.

Training to ensure proper use of PPE was highlighted as important. Medical training of care staff showed that the understanding of the correct use PPE within care homes is low. Proper training of staff is important to ensure that PPE is used correctly.

As the prevalence rate falls, viral genome sequencing is likely to play an increasing role in managing new infections.

At this week’s DELVE meeting, there were discussions on 1) The New York outbreak – strict lockdown followed by protests in the last two weeks but there has not been the expected peak from these. Some hypotheses that ‘superspreaders’ such as taxi drivers and those in key occupations have already been affected (died or developed some immunity). 2) In the context of care homes, there was an argument made that care homes may have already developed a level of immunity among their staff.

Easing care home restrictions – what criteria should be used and what is meant by easing restrictions.

A challenge is that care homes are not single entities but groups. If decisions are made on care homes about meeting criteria this would need to apply across the board. To introduce visiting – need to consider whether to test visitors, use Test and Protect to monitor any possible new cases.

The impact of no visiting to those with cognitive decline was noted. There have been a number of anecdotal articles about the decline of residents relating to lack of visiting. There were suggestions that they should wear full PPE and receive training to wear this properly. Relatives and close friends are likely to be highly motivated to ensure they comply to protect residents. This needs to be understood in order to assess the balance of harms. Further information is needed on whether relatives in full PPE would cause more harm/distress to residents than not wearing it. Care homes should advise what they think is best here and consider what potential harms exist and what practical measures could be put in place.

Suggestions were made that If some care homes are free of infection, those should be the ones where relaxation of measures start – rather than treating the whole sector as one. Acknowledge that staff move between homes and this may be more complicated in practice.

Homes with non-elderly residents (e.g. children or disabled adults) may need to be treated differently given the lower risk they face.

Summary - More clarity on data is needed, including understanding data from the VIVALDI study. The training of staff may not have been sufficient in the past; now we must ensure adequate training is given to staff and visitors. Surveillance through sequencing likely to now be increasingly used. The identification of early warning indicators is key for care homes. Important to take into account the balance of harms and risk, as well as the rights and choices of residents.

What criteria to base the go/no-go decision on? Is there existing evidence from elsewhere that can be used to support this?

Question – is there any data available on deaths attributable to the social harm of isolation? Not from death certification as this is focussed on biomedical causes. Qualitative research would be needed for this. It was noted that this should be an area to explore for further research.

Action: [Redacted] and [Redacted] to lead work on possible criteria for easing of restrictions in care homes.

Testing update and recommendations

Andrew Morris had joined the meeting and took the Chair.

On the minute last week there was an ask to put forward recommendations on testing. The Chair noted that this is ongoing and invited group members to comment on the paper submitted.

The need for a statement on testing strategy has arisen from many places. The paper states some principles for testing in COVID-19. Upstream determinants of the test are important, alongside the test itself. The speed with which a test result can be obtained changes its use and its impact. The PCR test is a diagnostic test and its utility in screening is not perfect. There is not an understanding of the gold standard of test for PCR testing of asymptomatic individuals. 

Who to test – the use of testing for case identification is still a problem. Test and Protect for it to be effective requires a large proportion of cases to be identified. Atypical symptoms may be an issue and may need more targeting.

Lack of data on what proportion of those who need testing who are getting this done.

Question - Agreement needed on testing contacts to find secondary cases, as well as public information campaign on testing for the public. This is important given the changing strategies through the pandemic (e.g. stay at home).

Could we increase the number of patients we detect if we widen the list of symptoms? Good that taste and smell has been included. Abdominal presentations in particular might swamp resources. Balance needs to be struck for the best sensitivity, to avoid overwhelming the system. Definition was based on early cases at the stage where this was thought to be a respiratory syndrome.

Contact tracing and backwards contact tracing – having a means of identifying when/where someone became infected and going back to test people who were there at the same time – is more targeted and effective than general testing.

Payback on R is identifying pre-symptomatic and asymptomatic individuals and ensuring quarantine reduces the risk of transmission. The concern about false positives may not be as important as the risk from false negatives. ONS type survey in Scotland to get more accurate picture of number of cases in Scotland is attractive in theory but presents problems in practice. Group members who had spoken to Public Health England contact about Test, Trace, Isolate mentioned reports of increased resistance to isolating. Adherence is an important challenge. 

False positives – can be very harmful if people are stopped from seeking treatment because they are false positives (e.g. chemotherapy).

Double testing – releasing those in quarantine who travelled to the UK, if two tests come back negative was discussed at SAGE as something being considered. This would have implications for Test and Protect as there would be impetus for a change in policy for residents if being extended to those travelling to UK.

Social norms – not staying home from work when ill is a widespread norm in the UK. Need to change norms by staying home when suspect being unwell. Lack of detriment and need for ongoing public sector support but also a need to engage with private sector to see what positive incentives can be given to make isolating less onerous.

Need for symptomatic individuals to come forward for testing and need to ensure they are supported. Need for more/better quality Scotland data. ONS data has very few positives from a large sample, with a large margin of error and data is just from community, not care homes. More effective to enhance testing capability to create picture of Scotland from testing being undertaken.

Action: Chief Statistician to send contribution to testing paper. All to comment by Sunday.

Action: Secretariat to send a summary of the timescale and ongoing requests to the advisory group.

BAME paper

Higher infection rate is seen in BAME groups. A paper has been put together with short-medium term recommendations. Welsh government is actively stratifying health professionals. BMA is calling for this in Scotland. Risk stratification tool being created for England. It is likely Scotland will need to adopt this approach. Tools likely to show more individuals in ethnic minorities. Lack of ethnic minority media outlets at FM lunchtime briefings cited as an example of the lack of engagement with ethnic minority groups. Paper makes recommendation on this as well as other issues.

Vitamin D supplements – why being recommended when there is no evidence of this effectiveness?

General lack of engagement with the public – since lockdown, there has not been as much proactive communication about the importance of this next stage. Communication needs to be genuine – household sizing increasing (south Asian families typically larger), lack of consideration for major festivals.

Action: By Sunday, group members to provide comments on the paper; aim to provide final draft on Monday. Letter to be submitted to CMO by 25 June

CMO letter

Final comments requested from the group by Sunday.

CSA update

New education sub-group discussions ongoing.

SAGE feedback

DCMO will circulate a note. Key issues were: repeat testing. Public Health England epidemiology teams have been looking at data and suggest double testing reduces number of infected people. Could be used as part of strategy to release from quarantine earlier (and possibly release from self-isolation earlier).

Countries that have concentrated on superspreading events from the beginning seem to have achieved greater control on the virus (e.g. Japan). This would require backwards contact tracing. A measure of the effectiveness of the Test & Protect programme will be its ability to identify unlinked cases.

Change not currently proposed for two metre rule. Discussion around the risk of public toilets (medium risk, high uncertainty).

Forwarding planning – group to articulate likely big issues that will arise with a view to two substantial discussion topics at each meeting. Suggestion that the group may need to reintroduce an additional meeting each week; agreed for now to extend future weekly meetings to two hours.

The chair extended his thanks on behalf of the group to Niamh for her work leading the Scottish Government’s support of the C-19 Advisory Group.

Action: DCMO to circulate a note on SAGE meeting.

Action: Secretariat to adjust meetings to twohours. Structure will be two major items of 30 to 35 minute each with additional rapid response on other items.

Summary notes

Items and actions

1. The Advisory Group discussed the infection prevention and control (IPC) measures that have been implemented in care homes. The group noted the importance of such measures in preventing additional COVIDBON-19 cases.
2. As part of the discussion on IPC measures, the group considered how and when such measures may be able to be decreased and what systems would need to be in place to enable these to be rapidly reintroduced if the risk of a further outbreak became were to increase.
3. The group recognised the impact that the absence of visiting can have on residents of care homes. The group reiterated the importance of taking into consideration the balance of harms when deciding whether to ease restrictions on visiting. The group continues to consider emerging evidence in this area.
4. The group considered available data on testing relating to the use of PCR tests. It was noted that this type of test is most effective as a diagnostic tool. In addition, group members raised the growing importance that serology testing will have the management of the pandemic.
5. The group discussed the importance of the public’s adherence to measures. Part of this will require some normative changes, notably urging those who feel unwell not to ’soldier on’ as well as encouraging them to get tested immediately. The group discussed the importance of supporting individuals who are asked to self-isolate and what external factors could support this.
6. The group acknowledged the ongoing work of the Expert Reference Group for the impact of covid-19 on minorities. They discussed some short and medium-term recommendations that can be provided to the Scottish Government on this issue.