Coronavirus (COVID-19) advice for people on the Highest Risk List: evidence review

This report presents key evidence underpinning our advice to people on Scotland's highest risk (formerly shielding) list.

Background to Scotland's Shielding List

1.1 The Scottish Government's Shielding strategy was designed to protect those who may be at significantly increased risk of serious illness or death from COVID-19 by supporting them to stay at home and limit their exposure to the virus.

1.2 With little data available about COVID-19 risk factors at the outset of the pandemic, the UK Chief Medical Officers agreed a list of conditions and treatments considered to increase risk, based on our understanding of individuals' vulnerability to other known respiratory viruses.

1.3 The Shielding List was created in March 2020.Around 180,000 people in Scotland, considered to be at highest clinical risk from COVID-19, received a letter from the Scottish Chief Medical Officer, advising them to strictly self-isolate (shield) for a 12- week period. The Shielding period was extended further with some relaxations of the initial strict self-isolating shielding guidance until 31 July 2020 when Shielding was paused.

1.4 By this stage, the evidence, primarily from an evaluation of the Shielding Programme conducted by Public Health Scotland[2], pointed clearly to the significant and detrimental impact of shielding on people's physical and mental health and wellbeing. Our aim moved to provide information, advice and tools to enable and empower those at highest risk to make informed decisions about their day to day activities and interactions; and, to consider what level of protection was right for them, as well as to support physical and mental health and wellbeing more generally.

1.5 User research has been undertaken with people on the Highest Risk throughout the course of the pandemic to better understand the impacts on their lives. The first findings from a survey by Public Health Scotland of the shielding group were published in September 2020. This showed that people who were advised to shield had mostly followed the advice, but that the shielding experience was difficult, in particular for socio-economically vulnerable groups[3]. The first full findings from the evaluation, which covered the period between March and August 2020, were published in January 2021. This found clear evidence that the shielding advice changed people's behaviour and that the shielding support addressed real need.

1.6 Public Health Scotland was then asked by the Scottish Government to evaluate the guidance and support offered to the highest risk group following the pause in shielding. A second survey was run and the findings from this were published in March 2022. This findings highlight ongoing negative impacts on the lives of people in the highest risk group, but also show that the advice and support offered to the highest risk group made a difference[4].

2. Highest Risk List Criteria

2.1 The conditions and treatments included in the initial shielding list were:

  • Solid organ transplant recipients who remain on long-term immune suppression therapy.
  • People with specific cancers.
  • People with severe respiratory conditions including all people with cystic fibrosis, severe asthma and severe chronic obstructive pulmonary disease (COPD).
  • People with rare diseases and inborn errors of metabolism that significantly increase the risk of infections (such as severe combined immunodeficiency and homozygous sickle cell).
  • People on immunosuppression therapies sufficient to significantly increase risk of infection.
  • People who are pregnant with significant heart disease.

2.2 As evidence of COVID-19 continued to emerge, a better understanding of the wider range of risk factors putting individuals at increased risk of becoming seriously ill from COVID-19 has developed and the following conditions were added:

  • People on home oxygen
  • People with severe bronchiectasis and pulmonary hypertension
  • People who have had their spleen removed
  • People on renal dialysis
  • People with Down Syndrome
  • People with chronic kidney disease

2.3 Clinicians were able to add people who did not fall into any of the six pre-defined groups, based on their clinical judgement.

2.4 As at 21 February 2022, 177,475 people in Scotland were identified as being at highest risk to COVID-19 and were on the Highest Risk List[5]. This makes up around 3% of the general population.

Figure 1 – Shows the seven groups which make up the Highest Risk List.
Figure 1 shows the seven groups which make up the Highest Risk List. These include transplant, cancer, respiratory, rare disease, immunosuppression, pregnant with heart disease and clinician identified. The respiratory group makes up the largest proportion of the Highest Risk List, followed by the clinician identified group and the immunosuppression group. The pregnant with heart disease group makes up the smallest proportion of the Highest Risk List. The same individual may be counted in more than one group.

*The same individual may be counted in more than one group.

3. Timeline of advice

3.1 Scotland moved beyond Level 0 in August 2021 where precautionary measures remained in place for the general population. This advice and baseline measures continued from August 2021 to March 2022. The publication of the update to Scotland's Strategic Framework[6] in 2022 made clear that due to the progress in vaccination and treatments, the intention was to rely much less on legal requirements going forwards and much more on people and organisations taking basic, sensible steps to reduce the risk of and harm from COVID-19.

Figure 2 - Timeline of Advice for Highest Risk List.
Date Summary of Advice for Highest Risk List
Mar 2020 HRL created (circa. 180,000 people). Advice to shield for 12 week period.
Jun 2020 Shielding extended for a further 4 week period.
Aug 2020 Shielding paused. HRL to follow general population advice.
Oct 2020 Introduced Protection Levels and Extra Advice. HRL advised not to attend work/school/college in Level 4 or above.
Apr 2021 Scotland move to Level 3. HRL advised safe to return to work/school/college.
Jul 2021 Scotland move to Level 0. HRL to follow general population advice, unless advised otherwise by their GP or clinician.
Aug 2021 Scotland moved beyond Level 0. Protection measures for general public remained in place.
Nov 2021 Update to Strategic Framework. Protective measures for general public remain in place.
Feb 2022 Update to Strategic Framework. Health measures and adaptations to be Scotland's primary means of managing COVID-19.
Mar 2022 Scotland removed some protective measures. Legal requirements to wear face coverings in public places remained in place.
Apr 2022 Scotland removed final legal measures.
May 2022 Retiring of HRL. Identification process to be stood up. Guidance for people who are severely immuno-suppressed to be published.



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