4. Who we test
Test to Diagnose
Under Test to Diagnose, anyone with one or more of the three core symptoms in the case definition – fever, new persistent cough, and loss of taste or smell – is encouraged to self-isolate to book a test as quickly as possible. We recognise a wide range of other symptoms has been identified as potentially indicative of COVID-19. From end of March, where GPs have a clinical concern that a patient without any of the three core symptoms may have COVID-19, they can advise that patient to book a PCR test through the usual booking portal.
Test to Care
Under Test to Care, anyone in hospital who develops symptoms of COVID–19 is tested promptly to ensure both optimal clinical care for them, and appropriate cohorting to minimise risk of in-hospital transmission either to staff or other patients. In addition, all emergency admissions are tested. All people undergoing planned admission to hospital are given a PCR test 72 hours before admission via NHS Scotland testing routes, and are only subsequently admitted when a negative test result has been confirmed. All new care home residents, whether from the community or hospital, are tested prior to admission. COVID recovered patients in hospital require two negative tests prior to discharge to a care home.
Test to Protect
Under Test to Protect, all patient-facing healthcare workers, alongside Scottish Ambulance Service and NHS24 call handlers, test twice weekly using LFDs. Since roll-out commenced in November 2020, Public Health Scotland has reported that over 778,000 tests have been self-reported by in-scope healthcare workers (cumulative as at 15 March 2021). Of those reported, there have been over a thousand asymptomatic positive test results identified.
As we continue to expand our testing capacity, we are finding more asymptomatic cases amongst healthcare workers resulting in an increase in positive cases. However, by identifying asymptomatic but positive members of staff as early as possible enables them to leave the workplace and self-isolate immediately, in line with national guidance, thereby breaking chains of transmission.
Alongside robust infection prevention and control (IPC) measures in hospital and other care settings (including the appropriate use of PPE, extended use of face masks and coverings, physical distancing and outbreak management), the addition of asymptomatic staff testing has helped support a reduction in hospital-onset COVID-19 cases since January 2021.
Roll-out of twice-weekly lateral flow testing to all patient-facing primary care healthcare workers started on 15 February 2021, meaning approximately 58,000 staff across patient-facing teams in general practice, dentistry, optometry and pharmacy, across communities, have access to twice-weekly lateral flow testing. All hospice staff are also eligible for twice-weekly testing.
In adult social care, all care home staff receive twice weekly testing; all visiting professionals to care homes receive routine testing; and family and friend visitors to care home residents are tested on the day of the visit as an additional layer of protection.
Care at home staff began routine testing for adult services from the 18 January (adult day centres/day services, care at home, personal assistants, and sheltered housing/housing with multiple occupancy). This was implemented by the end of February – one month ahead of the planned full roll out date.
Across all these social care groups – visiting professionals, care at home staff, family and friend visitors, and care home staff – Public Health Scotland figures to date have reported over 500 asymptomatic positive results.
Expanded testing for social care staff groups began on 8 March (for children's and young people's personal assistants and care inspectors visiting children and young people services). Further testing for staff will be phased from March for the following people working in care roles: children's care homes, children and young people community services, addiction, homelessness, mental health, learning disability, women's aid shelters and social workers not yet covered by testing. Work will also commence to examine non-registered services that provide support to vulnerable groups.
Test to Find
Since 18 February, all close contacts of index cases have been advised to book a PCR test between day 3-5 from exposure to a confirmed positive case. Testing is not an alternative to isolation and individuals who test negative are still required to complete the 10-day self-isolation period. Testing close contacts will allow cases that might otherwise have gone undetected to be identified and further chains of transmission to be broken by identifying and isolating potentially infected contacts. It will also provide further intelligence to public health teams about secondary attack rates (the probability of infection occurring among close contacts of confirmed cases) and high-risk settings, by highlighting where there may be a higher risk of transmission to contacts.
At a community level, Test to Find is a core part of the rationale for Targeted Community Testing, with proposals developed with local partners to address problems of stubbornly high transmission, or rapidly rising transmission, or specific transmission risks in local communities. Proposals for Targeted Community Testing have now been agreed with 25 local authorities across 10 Health Board areas.
We will introduce testing of staff working in prisons to reduce the risk of asymptomatic prison staff importing COVID-19 into the prison environment. We will start with three prisons to assess the operational feasibility and public health impact of this type of testing. Subject to a successful initial phase, we will expand testing to further prisons in due course.
We will also build on our existing programme of offering testing to students at times of large population movement (before and after the end of the first semester), to include extending access to PCR testing to students close to their non‑term‑time address prior to travelling to accommodation at university or college. Plans are also being developed to roll out regular (twice‑weekly) testing for university and college students and staff.
Quarantine testing was introduced with the new Managed Isolation policy for international arrivals to Scotland from outside the Common Travel Area from 15 February. All arrivals are tested twice during their quarantine period – on day two and day eight of the ten-day quarantine. All day two positive test results are sent for sequencing in order to detect any possible variants of concern.
Test to Find has also been a core part of outbreak management since the beginning of the pandemic, with mobile units deployed on the request of outbreak Incident Management Teams or Directors of Public Health to enable the testing of whole workplaces, or communities, or other locations of outbreaks. This testing continues on a case-by-case basis. Through our Community Testing programme, we have worked with the Scottish Ambulance Service, which operates the Mobile Testing Fleet in Scotland, to expand the potential of the current mobile fleet (42 vehicles) through a flexible staffing model that enables up to 84 communities to be served by the fleet, for sustained targeted community testing or for outbreaks.
Test to Support
Regular asymptomatic testing is now also available at certain food production and food distribution businesses, including places like dairies, abattoirs and meat and seafood processing plants. These are settings that present a higher risk of transmission due to factors like low temperatures, high humidity and limited ventilation. Under the scheme, which is voluntary for businesses and staff, eligible businesses are provided with free LFDs. Any positive tests are then confirmed by a PCR test. By taking part in this scheme, food businesses are helping to support their workers and to prevent outbreaks and minimise the risk of closure. They are also helping to minimise the risk of any cases or outbreaks in their premises spreading into the wider community. Businesses that are interested in participating are invited to contact FoodSupplyInformation@gov.scot.
Under the Schools/ELC Asymptomatic Testing Programme, twice-weekly at-home testing using LFDs is being made available to all staff in primary, secondary and special schools, and all secondary school pupils (with the S1-S3 cohort due to be included in the testing offer as part of an expected fuller return after the Easter break, which will be subject to continued progress in suppressing the virus). Staff in school-based early learning and school-age childcare settings will also receive testing as part of this phase of the programme.
The goal of this testing is to identify staff or young people who have the virus but do not have symptoms and require them to self-isolate, thus breaking potential chains of transmission early and minimising the risks of outbreaks in schools. Test kits are being supplied to all schools in Scotland for onwards distribution to those who wish to take part in the programme. Participants will then test at home and record results using a digital portal (or by telephone if they prefer). Anyone testing positive should self-isolate according to guidelines, and ensure they take a confirmatory PCR test to minimise the risks of false positives.
Phase two of the Schools/ELC Asymptomatic Testing Programme will see all standalone day care of children settings, providing early learning and school age childcare services, receive the same offer of twice-weekly lateral flow testing at home to break potential chains of transmission early and minimise the risks of outbreaks in settings. Preparation for this expansion is underway and test kits are expected to be available for staff through settings by the end of March.
To support the safe running of essential services, routine asymptomatic testing has commenced in the control rooms of Scottish Ambulance Service, Police Scotland and Scottish Fire and Rescue Service as well as NHS24 call centres.
Previous iterations of the testing strategy have made it clear that we are taking a risk-based approach to testing in workplaces. We believe that this is the most effective use of testing capacity and will ultimately allow us to open the economy in a more sustained way. We will continue to identify sectors which would benefit from asymptomatic testing based on the intelligence on risk and challenges around other mitigations.
Alongside this we will ensure that our community-based testing is engaging effectively with local businesses and workplaces. We will work with local heath partners to ensure that appropriate local businesses within high prevalence areas are fully included in community testing programmes, providing a coherent and targeted approach where prevalence of the virus is high. We will continue to engage with business organisations and sector bodies on our testing regime.
Test to Monitor
Scotland continues to invest in surveillance testing to monitor prevalence of the virus at a whole population level and in particular workforces including health and education. Our approach to Test to Monitor – using population studies, wastewater testing and whole genome sequencing – is set out in Section 3: How we test.
Three Phases of Strategic Framework
The updated Strategic Framework presents three phases as we exit lockdown, linked to levels of prevalence and progress with the vaccination programme:
1. Moderate-low level of prevalence nationally. Early vaccine roll-out.
2. Very low level of prevalence nationally. Widespread vaccination (Joint Committee on Vaccination and Immunisation Group 1-9).
3. COVID no longer a significant threat to public health. Maximum vaccine roll-out.
The role of testing and the relative importance of the six purposes for testing will adapt as we go through these phases.
Phase 1 – Moderate prevalence nationally
In the first phase, gradual easings of restrictions within Level 4 are taking place, when data indicates it is safe to proceed. These gradual changes are conditional on meeting the WHO six conditions for easing restrictions. The earliest changes began on 22 February, and included the opening of early learning and childcare and schools for years Primary 1 to Primary 3, and a very limited number of senior phase pupils attending secondary schools; and the opening of care homes to visitors to enable meaningful contact between residents and family and friends.
Further gradual easings are proposed, subject to continued evidence of sustained progress in reducing transmission, including the return of more children and young people to schools and the phased return of a small number of university students for in-person learning.
The role of testing in this phase is to support these individual settings as they return, in particular in education, to find cases and mitigate the potential for this return to increase transmission (Rt). The schools testing programme and the extension of higher and further education testing to enable routine testing for on campus students and staff, and the testing of family and friend visitors to care home residents, are all testing that is in place to support this return.
Another key role for testing in this first phase is in mitigating the risk of import. Imperative in this first phase to enable progress to the next phase of a return to a levels approach, is maintaining and building on the continuing progress we are making in reducing prevalence and harm, through our vaccinations programme and through our range of protective measures including testing, contact tracing and supporting isolation. To do this, we will maintain our vigilance to reduce the risk of importation of the virus, and identify and isolate any new variants of concern imported.
Since 18 January 2021, passengers have been under a legal obligation to get a COVID-19 test before they travel. We will continue to make it a requirement for passengers travelling to Scotland from outside the Common Travel Area to be able to certify they have a valid negative test result from the three-day period before travel.
We will continue to make it a requirement for all direct international arrivals to Scotland from outside the CTA, or those arriving from Ireland if they have passed through a red list country in the last ten days, to quarantine in managed isolation facilities and be tested on day two and day eight of their quarantine. In addition, those arriving from within the CTA who have travelled through a non-acute risk country in the ten days before arrival in Scotland must take tests on day two and day eight of their self-isolation-at-home period.
Phase 2 – Return to levels
Subject to passing a gateway condition of all JCVI priority groups 1-9 being offered at least their first vaccine dose, and evidence of all six WHO criteria for easing restrictions being met, Scotland will return to geographically variable levels of restrictions, based on prevalence, in phase two. This will enable the graduated opening up of social and economic activity at a pace that is safe given epidemiological conditions.
Testing for all six purposes will continue to play a critical role in this phase. This phase is likely to be characterised by a move from sustained community transmission to a pandemic phase characterised more by individual outbreaks, in particular in those settings where we have experienced outbreaks to date and which have not necessarily had the additional protective effect of the vaccination programme. This includes some workplaces where work cannot be done from home and certain closed settings.
In particular, test to Find will continue to be key to active case finding asymptomatic cases in workplaces to enable asymptomatic positive cases to isolate and not attend work, mitigating the risk of an outbreak beginning, or minimising the size of potential outbreaks.
As contacts increase, as schools return and economic and social activity opens up, we expect the number of close contacts of index cases to increase and close contact testing to be key in find cases amongst those known to have been exposed to the virus and therefore potentially infectious.
An increase in contacts and a return to a phase characterised more by outbreaks than by high levels of sustained community transmission will also require continued emphasis on Test to Support the resilience of essential services. We will continue to consider cases for extending routine testing to support this resilience, subject to available capacity.
Given this phase involves a return to geographically variable levels, the role of the Targeted Community Testing programme will grow in importance through supporting rapid and flexible deployment of additional testing capacity at the earliest signal of rising incidence (for example, through the expanded wastewater testing programme) and also asymptomatic testing capabilities to support local areas to target testing programmes in workplaces or other contexts where they have known concerns.
There are also a number of significant events potentially on the horizon as we move through 2021. These include May's Scottish Parliamentary Election, summer sporting and cultural events if conditions allow, students returning in September, and the COP26 climate summit in Glasgow in November. Where testing can play a role in supporting the safer operation of some of these events as an additional measure, we will learn from existing pilot activity across the UK related to events and use Scotland's testing to support these events in appropriate ways.
Phase 3 – COVID-19 no longer a significant threat to public health
On maximum roll-out of the vaccination programme, and maximum suppression of the virus to the lowest possible level, there is likely to come a phase when COVID-19 is no longer a significant threat to public health, and we learn to live with COVID-19 as a permanent feature of our lives. Public health measures will be ongoing in this phase, including testing to diagnose those with symptoms, testing for clinical care in healthcare settings, and testing to monitor population level prevalence, as occurs in the long running surveillance of other respiratory virus infections.
As national prevalence reduces to this very low level, with potential seasonal increases as with other respiratory disease, the role of national routine asymptomatic testing programmes will change. Principle 4 of our Testing Strategy Principles is that our approach to testing takes full recognition of the limitations of testing (particularly at low levels of disease prevalence) as well as the opportunities of testing.
At these low levels of disease prevalence, the likelihood of positive test results actually being false positives – the person tested is not infectious – increases. At a certain point, this means the benefit of routine asymptomatic testing may be outweighed by the harms caused. These risks – of false positive results and false negative results – are related to both the attributes of the test and the likelihood of there being cases in a community.
As we return to geographically variable levels, some parts of the country will experience this fine balance of benefit of routine testing compared to harms sooner than others. To mitigate the risk of false positive results requiring an individual and their household to self-isolate unnecessarily, as long as routine testing programmes continue we will continue with our current policy of advising all those who receive a positive result with an LFD test to book a confirmatory PCR test. To mitigate the risk of false negative results we will continue to stress in all guidance, training and national and local communications that no test is 100% accurate, and that testing does not replace the need to comply with all other mitigations in place.
Monitoring and evaluation will be critical to informing decision making on when and where this balance is reached. Monitoring data will shortly be available across testing pathways and regularly published by Public Health Scotland in their weekly COVID-19 report. Work is also under way to develop an evaluation framework for this Strategy drawing on routine testing data, national surveys and local evaluations. We anticipate that interim results from the evaluation will be reported on in summer 2021.