5. Scotland's approach to managing COVID-19 outbreaks
When the SARS-CoV-2 virus – the virus that causes COVID-19 – was first detected in Scotland, each new case was isolated and their contacts identified and quarantined to try to stop the virus spreading any further. As the COVID-19 virus spread across the country it could no longer be controlled by a containment response, we then moved to a delay phase and the nationwide lock-down was introduced. This lock-down was needed to stop community transmission of the virus across the population of Scotland.
As we release from lock-down, there remains a risk that the virus will break out into the wider population again. This is why we have expanded our contact tracing system, and published additional guidance to support businesses and other establishments to collect customer and visitor data to ensure comprehensive contact tracing can be carried out in the event of a localised outbreak linked to a specific venue.
The virus could re-emerge as a single workplace cluster; a local community outbreak; within health or care settings as a wider local or regional level problem; or a more systematic breakdown of virus control with spread occurring across all of Scotland again.
There are well established mechanisms in place to manage this possibility involving a multi-tiered, multi-agency coordinated approach. The procedures used to control outbreaks of any infection are set out in the Management of Public Health Incidents Guidance .
This guidance provides information to support NHS boards in preparing for or in response to public health incidents. It outlines the roles and responsibilities of all relevant agencies involved in the event of an outbreak and provides direction around the process of identification, investigation, risk assessment and incident evaluation. It is intended to be strategic but not prescriptive, allowing for flexibility so that NHS boards can respond appropriately to each incident.
It sets out a tiered framework for public health incident management. This starts with an outbreak where the local impact will be limited and that will be managed locally (Level 1) by an NHS Health Protection Team led Incident Management Team – up to the highest level national emergency situation (Level 5) which involves a full scale Scottish Government Resilience (SGoRR) response and national level leadership.
In many cases clusters and small outbreaks will be defined as Level 1. However, it is clear that overall in the context of a pandemic, Scotland is effectively at incident Level 5 where there is a major ongoing impact on public health with major disruption of societal functions. This justifies, therefore, a very close relationship between national and local decision making and incident management. Local decisions can have a national significance and vice versa.
Levels of Incident
Level 0: Initial identification of potential incident
Significance in public health terms not clear
Level 1: Limited Local Impact
No significant risks to public health beyond the immediate group/ setting affected in a single NHS board area
Level 2: Significant Local Impact
Significant risk to public health beyond group/ setting affected mainly in single NHS board area
Level 3: Significant Wider Impact
Significant risk to wider public health affecting more than one NHS board
Level 4: Severe Local or Wider Impact
Major ongoing risk to wider public health affecting one or more than one NHS board with significant disruption of services
Level 5: Catastrophic Impact
Major ongoing impact on public health with major disruption of normal societal functions
Source: Adapted from Management of Public Health Incidents: Guidance on the Roles and Responsibilities of NHS Led Incident Management Teams Scottish Health Protection Network Scottish Guidance No 12.1 – interim update (2020)
Outbreak management follows an established process of investigation to establish the who, what, why, when, where and how of any incident. This includes investigation of: epidemiological data; the source (this may include laboratory investigation); and the method or environmental reason for the exposure. This will be complemented by a risk assessment to determine interventions or control measures that have to be put in place to minimise the impact and the development of communications to explain what has happened and what to do next.
Following the notification of any outbreak, what follows is well-established partnership action. There are well developed relationships and protocols through which information is passed and decisions are made both at the local and national level between public health, resilience partnerships, Scottish Government and wider partners.
In responding to an outbreak, local partners will make use of a wide range of tools and techniques. This will include: access to testing, including mobile testing units; potentially extensive contact tracing, utilising both local teams and national support; enhanced surveillance to access and assess all available data and intelligence; and support from a range of partners for all those involved. These are the critical capabilities underpinning our Surveillance and Response approach.
Many of the situations we might face can be dealt with effectively by our Test and Protect service. Other situations may be more complex involving higher levels of risk. This will include: settings where people are in proximity (including workplaces); settings where exposure to COVID-19 is more likely (including care homes and hospitals); situations where the people involved are at higher risk (including older people and BAME community); and also situations which cross geographical and organisational boundaries.
In more complex, higher risk situations, in addition to Test and Protect, direct, practical intervention from public health teams and partners "on the ground" is likely to be required. We have already seen this in complex settings such as care homes. In the weeks and months ahead we may see outbreaks in other complex and higher risk settings, such as food processing plants, schools, and on public transport.
The national and public interest in any COVID-19 outbreak will remain high over the coming weeks and months as will the potential societal impact. Local outbreaks could have national implications and in this regard Scottish Ministers will wish to remain informed and engaged on local decision making.
As set out in section 4, decisions at both the national and local level will be informed by data that will be visible to all partners for interpretation. If any outbreak is reported, Local Health Boards, Public Health representatives and local resilience partners, including local authorities and the emergency services, will engage at an early stage with national advisors and representatives including the Chief Medical Officer. Scottish Ministers will be informed and the engagement and communication that follows will focus on public health and public safety.
Timely and clear communication will be essential and it will be a priority to ensure that messages are issued at an early stage to raise awareness of actions that require to be taken. In all likelihood, this will involve complementary communications approaches at the national and local level.
Management of Public Health Incidents Guidance sets out in further detail the stages of escalation of any outbreak and who is involved at each stage. Where the Scottish Government is involved in the response to any outbreak, the principles of this engagement are set out in Preparing Scotland. This guidance on responding to emergencies brings together the implementation of the Civil Contingency Regulations, good practice and the integration of national and local planning for emergencies.
As we move forward it will be essential to keep under review how this process of early identification, escalation and decision-making is working. Over the coming months, the partners involved will continue to ensure that the response to any COVID-19 outbreak remains flexible enough to be appropriate to the local situations that arise. We will review how the process is working on a three monthly basis up to April 2021 to ensure that the response and level of engagement remains proportionate
Robust decision-making to determine the next course of action will be key to managing any outbreak, and further detail on how this will work is set out in Section 6.