Various questions regarding coronavirus contact tracing strategy: FOI release

Information requested

1) On what date was contact tracing as set out above first implemented in Scotland?

2) Is this process still in operation and if not, on what date was it terminated?

3) According to the statement referred to above, the advice given to close contacts of a person who has tested positive for coronavirus is:

"Mainly information on what to do if they become unwell or develop certain symptoms.
Anyone believed to be at higher risk of infection could be asked to self-isolate – remaining within their home and avoiding public places. These people will be in daily contact with health experts until they are given the all-clear.
Should a person develop symptoms, they are tested and given specialist care if they prove to be positive for the virus."

Please let me know

a) What guidance is used in in Scotland in deciding whether close contacts are advised to self-isolate?

b) How many people in Scotland have been advised to self-isolate because of contact with a person who has tested positive for coronavirus?

c) How many households in Scotland have been affected by (b)?

4) Please let me know what approach to contact tracing is taken in Scottish hospitals, when it came into effect, and whether and at what dates there have been changes to this policy. I am asking this because WHO advice for contact tracing in hospitals differs from its advice for contact tracing in the community, and involves testing of all staff and patient contacts, whether they show symptoms or not ("Considerations in the investigation of cases and clusters of COVID-19"  Interim guidance  13 March 2020 https://www.who.int/publications-detail/considerations-in-the-investigation-of-cases-and-clusters-of-covid-19 , p3). 

5) Please let me know of any assessment the Scottish Government has made of the need (or otherwise) to trace and advise contacts of suspected (ie untested) covid-19 cases in the community. This includes people who are self-isolating because they have mild symptoms but, in line with current advice to the public, have not contacted a doctor or telephoned NHS 24. I am asking this because WHO advice (p2 of the document cited above) is:

"For contacts of a suspected COVID-19 case, at a minimum, health authorities need to encourage respiratory and hand hygiene and may encourage, depending on the epidemiological context and resources available, self-monitoring for symptoms, social distancing, or quarantine."

6) Please let me know what constraints and challenges to contact tracing have been noted by the Scottish Government arising from costs, limited availability of equipment, staff or facilities, data protection considerations or any other considerations.

Response

1) On what date was contact tracing as set out above first implemented in Scotland?
Health Protection teams in Scotland have decades of experience in delivering contact tracing for a range of infectious diseases. It is an established process delivered by health protection professionals, dating back to the early 20th century. Contact tracing was therefore carried out for all cases in Scotland up until 13 March.
It was appropriate to put on hold contact tracing when it was announced the UK was moving from the ‘contain’ phase to the ‘delay’ phase on 12 March. The policy was changed to focus on providing the best care to help those who developed Covid-19, delaying and reducing the spread as much as possible, and protecting those who are particularly vulnerable.

2) Is this process still in operation and if not, on what date was it terminated?
On 12 March it was announced the UK was moving to the ‘delay’ phase, at which point those who displayed symptoms of a new continuous cough and/or a high temperature, regardless of their travel history or contact with confirmed cases, were asked to self-isolate.
We detailed our approach to “Test, Trace, Isolate and Support” in a paper published by the Scottish Government on 04 May 2020.
In Scotland, the contact tracing strategy for COVID-19 known as ‘Test and Protect’ (previously referred to as Test, Trace, Isolate and Support’ (TTIS)), a testing and tracing programme for confirmed cases and their contacts, was initiated in pilot form on 18th May 2020 in three NHS boards in Scotland (Fife, Highland and Lanarkshire); learning from these pilot sites helped to inform the full programme which was rolled out on 28th May 2020. Please note testing policy in Scotland was updated on 18th May 2020.
According to contact tracing guidance, please note the following definitions:
Case definition for individuals in the community
People with the following symptoms are advised to self-isolate for 7 days:
Recent onset (within the last 7 days):

• New continuous cough
  and/or
• High temperature
  and/or
• Anosmia (a loss of/change in sense of smell or taste)

Case definition for individuals requiring hospital admission:

• Clinical or radiological evidence of pneumonia
  or
• Acute respiratory distress syndrome
  or
• Influenza like illness (fever ≥37.8°C and at least one of the following respiratory symptoms, which must be of acute onset: persistent cough (with or without sputum), hoarseness, nasal discharge or congestion, shortness of breath, sore throat, wheezing, sneezing).

Clinicians should be alert to the possibility of atypical and non-specific presentations in children, older people with frailty, those with pre-existing conditions and patients who are immunocompromised.
Patients must be assessed for bacterial sepsis or other causes of symptoms as appropriate.

As of 18th May, a contact of a case is defined as follows:
A person who, in the period 48 hours prior to and 7 days after the confirmed case’s symptom onset, had at least one of the following types of exposure:
Household contact: Those that are living or spending significant time in the same household e.g. those that live and sleep in the same home, students in university accommodation that share a kitchen, sexual partners and people who have cleaned a household where a case lives without personal protective equipment.

Non-household contact:

• Direct contact: Face to face contact with a case for any length of time, including being coughed on or talked to. This includes exposure within 1 metre for 1 minute or longer.
• Proximity contact: Extended close contact (within 1 to 2 metres for more than 15 minutes) with a case or travelled in a small vehicle with a case.

3) According to the statement referred to above, the advice given to close contacts of a person who has tested positive for coronavirus is:
"Mainly information on what to do if they become unwell or develop certain symptoms.
Anyone believed to be at higher risk of infection could be asked to self-isolate – remaining within their home and avoiding public places. These people will be in daily contact with health experts until they are given the all-clear.
Should a person develop symptoms, they are tested and given specialist care if they prove to be positive for the virus."

Please let me know

a) What guidance is used in in Scotland in deciding whether close contacts are advised to self-isolate?
Health Protection Scotland’s website contains guidance covering a range of topics relating to Covid-19, and their 01 June compendium of resources and guidance links to the following publication regarding contact tracing in the context of Covid-19:
https://www.who.int/publications-detail/contact-tracing-in-the-context-of-covid-19

b) How many people in Scotland have been advised to self-isolate because of contact with a person who has tested positive for coronavirus?

This information is not available for the time when you corresponded with the Scottish Government.
However, information is now being published by Public Health Scotland regarding the numbers traced and isolated via the Test and Protect service.

c) How many households in Scotland have been affected by (b)?
The Scottish Government does not hold this information.

4) Please let me know what approach to contact tracing is taken in Scottish hospitals, when it came into effect, and whether and at what dates there have been changes to this policy. I am asking this because WHO advice for contact tracing in hospitals differs from its advice for contact tracing in the community, and involves testing of all staff and patient contacts, whether they show symptoms or not ("Considerations in the investigation of cases and clusters of COVID-19" Interim guidance 13 March 2020 https://www.who.int/publicationsdetail/considerations-in-the-investigation-of-cases-and-clusters-of-covid-19 , p3).
Please see the answer to Question 2 for the wider approach to contract tracing.

Specific points for the hospital setting:
A staff member who has been in contact with anybody who has tested positive for COVID-19 whether at work (most likely a colleague in communal areas) or in the community will be required to isolate for 14 days in line with advice to the general population. There is no need for other colleagues to isolate as well, although it is possible that if a member of staff tests positive, they may have had contact with multiple colleagues or have been exposed to the same source of infection. It is, therefore, important that staff wear appropriate PPE when caring for or working with patients, and use it with appropriate hygiene measures for donning and doffing and disposing of it safely. It is also important to adhere rigorously to social distancing with colleagues and other staff when not providing care, for example, when having coffee breaks.

A staff member who has been caring for a person who has tested positive for COVID-19, or who has symptoms of COVID-19 while the staff member was wearing appropriate PPE, in the majority of cases, will not need to isolate. These cases will be referred to the local health protection team (HPT) to advise on, but unless there are very specific circumstances around the contact, it is likely that the staff member will be advised that they can continue to work as normal.

A staff member who has been caring for a person who has tested positive for COVID19 or who has symptoms of COVID19 while the staff member was wearing appropriate PPE but the PPE has been breached will need to isolate for 14 days in line with the advice to the general population. There is no need for other colleagues to isolate as well, although it is possible that if a member of staff test positive, they may have had contact with multiple colleagues or been exposed to the same source of infection.

For the management of exposed staff and patients in health and social care settings who have previously had COVID-19 symptoms/tested positive, a second episode of symptoms requires isolation and repeat testing. The time between the first and second symptomatic episodes should be considered during the interpretation of a second test result. This is because, in some individual’s, virus may only be detectable for a few days, whereas in others it has been detected up to 7 weeks from symptom onset in one case (Tan et al. 2020). Generally, however, the detection of virus from the respiratory tract is highest around the time of symptom onset and gradually declines over time. 
Furthermore, it is not known how long any immunity to COVID-19 might last. We do know that antibodies to other human coronaviruses wane over time, and there are some reports of reinfection with homologous coronaviruses after as little as 80 days. Thus, reinfection of previously mild SARSCoV-2 cases is a realistic possibility. It is unclear if such reinfections will result in onward transmission, but that cannot be excluded. It is, therefore, recommended that a HCW with a second compatible illness after recovering from a first confirmed or suspected illness should be tested again (by PCR). For HCW working with clinically extremely vulnerable patients, evidence of viral clearance (i.e. obtaining a negative PCR test result) may be required before returning to work, but this is subject to local policy.
Following initial piloting of the Test and Protect programme between 18 and 22 May 2020, the full programme was rolled out on 28 May 2020. Since 28 May, there have been no changes to the strategy (as at 09 June 2020).

5) Please let me know of any assessment the Scottish Government has made of the need (or otherwise) to trace and advise contacts of suspected (ie untested) covid-19 cases in the community. This includes people who are self-isolating because they have mild symptoms but, in line with current advice to the public, have not contacted a doctor or telephoned NHS 24. I am asking this because WHO advice (p2 of the document cited above) is: "For contacts of a suspected COVID-19 case, at a minimum, health authorities need to encourage respiratory and hand hygiene and may encourage,  depending on the epidemiological context and resources available, self-monitoring for symptoms, social distancing, or quarantine."

The Scottish Government’s approach on contact tracing is set out in our published strategy, published 04 May and linked at Q2 above, detailing the output of our assessment on the right approach to contact tracing at the current time.

6) Please let me know what constraints and challenges to contact tracing have been noted by the Scottish Government arising from costs, limited availability of equipment, staff or facilities, data protection  considerations or any other considerations.
The main challenge has been the ability to predict the number of index cases that are likely to need their contacts traced, and the number of contacts that each index case will declare, as the pandemic progresses (with periods of reduced and increased prevalence as a result of lockdown measures and their subsequent easing).

Additionally, the UK Government’s Scientific Advisory Group for Emergencies (SAGE) publishes information, where possible, relating to scientific advice guiding the response to Covid-19. More information about SAGE, and publications released, can be found at:
https://www.gov.uk/government/groups/scientific-advisory-group-for-emergencies-sage-coronaviruscovid-19-response

The minute from the 20 Feb meeting includes a discussion item on contact tracing which considered trigger points for halting contact tracing, and the implications of such a decision. It can be found at: https://www.gov.uk/government/publications/sage-minutes-coronavirus-covid-19-response-20-february-2020

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