- 19 May 2021
Attendees and apologies
Advisory group members
- Andrew Morris
- Dave Caesar
- David Crossman
- Nick Hopkins
- Tom Evans
- Nick Hopkins
- Audrey MacDougall
- Jim McMenamin
- Jill Pell
- Stephen Reicher
- Jacqui Reilly
- Chris Robertson
- Sheila, Rowan
- Aziz Sheikh
- Gregor Smith
- Devi Sridhar
- Mark Woolhouse
- Julie Anderson
- Catherine Bagot
- Cat Carver
- Gabe Docherty
- Daniel Kleinberg
Items and actions
The Chair welcomed group members and SG observers attending. Julia Anderson, Catherine Bogat and John Murphy were invited to this meeting as external observers.
The minutes of the previous meeting have been shared with group members for comments.
Subgroup leads were given the opportunity to raise their groups’ hot topics and key issues with the wider advisory group.
Primary schools and ELC have now returned. While there have been some large clusters these have been infrequent. Early assessment of data in England is ongoing. Current plans in Scotland are for secondary school to return in full after the Easter holidays. Assessment of changes to case numbers post-Easter will need to take into account the wider relaxations of measures to avoid case increases being disproportionately linked to schools. The success of the vaccination programme in the wider population continues to be key to driving low community prevalence.
There are many mitigations in place in schools, including blended learning where necessary. There are concerns that this could be increasing inequalities given the higher level of in-person teaching in private versus state schools.
International engagement has taken place to share key learnings between countries. Further international engagement is planned.
COVID-19 Nosocomial Review Group
The number of cases of nosocomial COVID-19 in Scotland has decreased substantially since the peak on week ending 17th January. The trend in the incidence of nosocomial COVID-19 follows the trend in the wider community population with a lag of approximately 2 weeks.
Key lessons learned exercises have been undertaken across Scottish health boards. Challenges recorded include physical distancing outwith the clinical area (e.g. cafeteria, changing rooms). Healthcare facilities is another area of work, including how ventilation can be optimised. The high risk (red) pathways where positive cases of COVID are cared for have very few staff testing positive. Patient and staff movement is a significant factor in the number of patient contacts and staff requiring self-isolation.
Lessons learned from large clusters (>20 staff/patient cases) – there is rarely a strong hypothesis for infections but the following factors (section 4.2) have been identified:
- Reopening wards or partial reopening of wards early due to bed pressures
- Maintaining acute specialist services e.g. CCU, acute stroke when bed pressures were high
- Staff not physically distancing (in clinical and non-clinical areas)
- Staffing turnover and staff to patient ratio issues, resulting from absence and movement between wards
- Patient movement between wards
- Ventilation issues were noted in three reports (5% of the large clusters reported) and none of the reports included specific hypotheses related to air-mediated or airborne transmission.
Testing is critical and should continue to be optimised. The investigation of a hospital with a large number of clusters has pointed to multiple introductions responsible for clusters introductions from the local population but also further afield, movement between wards. There is evidence of non-HAI cases within clusters. Some staff cases are community origin, some hospital origin and the direction of infection is unclear. Rigorous, sustained, consistent and vigilant implementation of IPC measures is key to reducing nosocomial risk.
The international guidance is broadly similar across countries for IPC measures in hospitals and in line with that published by WHO to date..
Scottish IPC guidance will have additional content to strengthen use of hierarchy of controls. Further areas of work will include consideration of what more can be done to optimise ventilation in healthcare settings, post discharge analysis (inclusive of readmission impacts), secondary and co-infection in COVID-19 patients (bloodstream and respiratory tract infections including Aspergillus and other fungal infection and wider impact on HAI and AMR and integration of genomic data with epidemiological data to better understand transmission dynamics in hospital settings.
The CNRG behavioural insights subgroup workplan continues to focus on enabling adherence to key IPC measures which are the defences in hospitals.
Minutes from recent meetings were circulated. The group has worked on areas such as waste water testing and genomic sequencing which have become important tools in our response to the pandemic. The issue of the persistent positive has been discussed at recent meetings. Further research into this area will take place.
The group considered a report from TestEd (University of Edinburgh) for the testing of students and staff where hypercube pooling is being carried out. This has potential for use in schools.
A subgroup on genomics has also met, leading to the award of funding for SARs-CoV-2 whole genome sequencing in NHS labs. Funding is being sought for this to evolve into a pathogen sequencing platform for the UK 4 nations.
The Chair noted the incredible effort of subgroups and thanked all those supporting them in their work.
The group were shown data on vaccination from the EAVE-II study. [REDACTED]
Action: the group to reconsider vaccine data at future meetings.
State of the pandemic
The upper limit of R has been at 1.0 for the past two weeks. The room for manoeuvre is limited given this. There is a marked impact of the vaccines in reducing hospitalisations and deaths. We are also seeing a reduction in transmission as a consequence of vaccine receipt in individuals. Frequent testing programmes have not been unmasking a large number of positive cases.
Behaviour changes and changes to mixing patterns, particularly in older people, show optimism from the population about the protection they receive from the vaccine. Group members considered whether messaging may need to evolve to take into account protection from the vaccine. For public adherence it is important to stress that progress is not inevitable but contingent on continued improvement. The public should not be seen as passive, but participants in getting to the point where these things happen. Messaging will increasingly need to become principles based – to help individuals make educated risk assessments, once we move on from strict rules. The CORSAIR data shows that 20% of those with symptoms get tested. There are still problems of supported self-isolation. Case finding and proper isolation are crucial to continuing to control the R number. B1.1.7 has proven very difficult to control and suppress and R has remained just below 1.
The number of tests per day is increasing and case numbers and deaths continue to fall. Broadly data can be cause for optimism. Test positivity is falling as a consequence of increased testing (such as of contacts of contacts). This is proving a significant challenge in interpreting data.
Recent studies have shown that there may be drop in compliance in those with COVID symptoms. Changes in neighbouring European countries are being closely monitored, particularly with regards to the levels of variants such as the South African variant. The particular variable to monitor in domestic data is S-gene target failure as a drop in rates of this (the Kent variant) could suggest variant replacement is occurring.
Israeli data showed a significant drop in hospitalisation as soon as 50% vaccination coverage of age groups was observed.
R is between 0.8 and 1.0 in Scotland. [REDACTED]
The risk of the third wave hospitalisation peak exceeding the spring 2020 peak is highest where vaccine effectiveness is diminished, including from variants.
Group members asked about the consideration of population heterogeneity in modelling and the unequal spread of cases across the population but also uneven uptake of vaccination. Continuing with current levels of vaccine we do not yet know if we can reach the herd immunity threshold. If we cannot reach the threshold, continued measures such as NPIs will continue to be important.
This item will be taken at the next meeting.
Action: the next meeting will consider international examples to consider the impact of vaccination schemes and key learnings from these.