- 15 Mar 2021
Attendees and apologies
Advisory Group members:
- Andrew Morris
- Dave Caesar
- David Crossman
- Tom Evans
- Nick Hopkins
- Jim McMenamin
- Jill Pell
- Stephen Reicher
- Jacqui Reilly
- Chris Robertson
- Sheila Rowan
- Gregor Smith
- Aziz Sheikh
- Devi Sridhar
- Cat Carver
- Gabe Docherty
- Richard Foggo
- Derek Grieve
- Daniel Kleinberg
- Marion McCormack
- Audrey MacDougal
- Alisdair McIntosh
- Arlene Reynolds
- Elizabeth Sadler
Items and actions
The chair welcomed group members, guests and SG observers.
Comments on the draft minutes of the previous meeting are to be provided to the Secretariat by 5pm Friday.
State of the pandemic
Scottish Government update
The group was received an update on Scottish Government plans regarding the publication of a routemap the following week on lifting lockdown measures. The proposed approach is cautious with time to assess the effects of changes as part of the process. The group was mindful of the impacts on NHS and care staff and the need to support resilience. The Chair noted that issues around lifting lockdown restrictions had also been discussed by SAGE.
In discussion, the group echoed the need for caution. It would be desirable to test more people, in order to catch more infections – even if this increased test positivity. Lagging indicators are a perennial issue but notable that deaths had started to decrease.
It was noted that models reflect the assumptions they’re based on. Even with optimistic assumptions, modelling suggested there was a quite high chance of a further wave. We know that vaccination is not 100% effective and not 100% of people are vaccinated. There is a need to drive down rates of infections. Decisions about NPIs in future need to be made when rates start to increase, not wait for them to hit thresholds.
Although there was increasing discussion about an endpoint to the virus, we need to be clear that it’s unlikely that things will change quickly – restrictions may have to be in place beyond this year. Nevertheless, there have been positive developments, including for instance Forth Valley’s assertive case finding, which was impressive and influential.
There was however concern that figures were no longer falling as fast as they had been and the R number was not now improving; likely due to the characteristics of the new variant. There was a need to consider the measures we have beyond standard NPIs – vaccination principally, including for children, once proved safe. Expanded testing would help, with new community testing potentially a game changer. Increased use of Lateral Flow devices could help.
It was observed that calculations for the road map are a function of the downward curve of infections and upward curve of mitigations - vaccination and NPIs including Test and Protect and making sure that environments are safe – both domestic and public. Inspection/certification of public spaces as compliant could be a measure to help tackle the virus and give people confidence to use shops etc which had been certified. It was suggested that there was a potential exit strategy if vaccination remained high through to summer. It may be possible to provide Lateral Flow tests via chemists for hospitality, if manufacturers were able to provide individual vials.
- SG to investigate any restrictions on the ability of manufacturers to provide individual vials to universities and others
While numbers had improved and suggested restrictions could be lifted it seemed likely that autumn would require continued vigilance – masks, social distancing etc. Public transport would be an issue. Rapid testing will be helpful but imperfect – US have tried (Trump White House had daily testing but still experienced outbreaks) but we need more precision. Not the answer in itself but it does help and we should test more, though with lower expectations. It was observed that there was a tension between those thinking we’re approaching an end state ‘back to normal’ and what the new normal may look like in practice. Next steps on testing need to be cautious to avoid sending wrong signals.
A question was asked about any signs of increased transmission in children. There was no direct evidence on transmission but analysis of infections showed that levels of the Kent virus had plateaued for children age 0-4, though they were decreasing for other age ranges, albeit more slowly than for other variants. This would continue to be kept under observation.
The Chair summarised the discussion, noting:
- Advisory Group happy to support development of the road map
- pace of re-opening needs to be slow and cautious – relaxations need to be extended over months - need to take a measured approach with a number of weeks between steps to judge impact of previous relaxations
- figures have improved but prevalence remains stubbornly high and may have plateaued
- relaxation needs to take account of fragility of health systems and staff and the need to support resilience
- evaluation of impact of relaxation needs to bear in mind that Imperial and Warwick models warn of danger of a further wave
- need to think about vaccines, TTI and other NPIs as part of normal life
- we can learn from experience elsewhere eg Denmark on testing
- need to look at investment in secure environments, including accreditation
Audrey MacDougall gave an overview of the latest modelling, including a slide looking at sequencing over the course of the year and showing the impact of travel over the summer holidays. It was noted that the R number has been at 0.7- 0.9 for some time now, which supports the need for a slow lifting of restrictions. Other modelling shows potential for serious worst case scenarios if vaccination is not effective, with a wide range of uncertainty. That uncertainty would reduce as we obtain more data and early indications suggest vaccination will be effective.
In discussion, it was noted that the effectiveness of vaccination on different age groups in terms of lives potentially saved was a powerful message. The reasons for the new variant’s transmissibility were still not known but that was likely to be the explanation for R not reducing beyond 0.7, which was similar to the levels in March/April. Data on public trust in Government showed significant difference between Scotland and UKG but there is not the same difference in compliance, which suggested that trust in the science was important in the longer term, which had important implications for the way decisions are communicated.
It was noted that the data showed that the level of infections in Scotland two weeks ago was half of that in England but the epidemic had recently been reducing faster in England than in Scotland and levels are now very similar. The reasons for this were unclear and needed investigation. There is a need to understand the factors behind the relative rates of decline – recent progress has slowed and driving down further will be tough.
The Chair updated the group on discussions at SAGE 81.
Elizabeth Sadler introduced the paper on vaccine certification. While it was too early for any scheme to be introduced – more information was needed on vaccination effects – the issues need to be considered now, including the technology and data needed to support a system, to ensure there is an option available. A system may cover international travel and domestic use – eg certification of vaccination plus recent test for care home visits. There were a range of ethical issues as well as the practicalities and data and quality standards would need work.
The group welcomed the paper. Accurate and timely data on vaccination and testing was an essential and there were clear domestic and international applications and issues. It was too early to be definitive about the effects of vaccination on transmission. Early indications were promising, though maybe not as positive as we would have hoped. The paper’s differentiation between personal safety and population effect was welcomed – equity and access issues will need to be overcome and inequalities addressed.
Evaluation needed to be considered, including work to scope the benefits and risks of giving people access to their information. It was suggested that preliminary work on people’s understanding would help design any research or trials. Research suggested a number of different ways to approach evaluation design e.g. vignette studies.
The Education and Children sub-group had looked at mitigations and the need to be stricter in scondary schools on distancing and masks, including issues of practicality in relation to access to masks. The group also discussed metrics for measuring the effects of return for P1-3 and comparisons with the approach in England. The Chair noted the good work being done by the group.
Information had been circulated on the work of the Nosocomial sub-group. The chair noted the on-going debate about PPE related to mask type being used for HCWs internationally. CNRG noted the science to date on droplet (for all suspected and confirmed cases) versus airborne precautions (which are risk based currently in line with UK IPC cell and WHO advice to date). CNRG had received presentations from Norway and Germany to date which indicated this was in line with their current concerns and that in Germany the move to wider N95 mask use in HCWs was a political directive rather than IPC advice based. CNRG had noted that risk of longer range aerosol risk was mitigated with ventilation optimisation and this had been subject to consideration at the point of NHS remobilisation by boards and was included in the IPC guidance to date.
CNRG had considered recent aerosol science publications and noted the need for clinical research in this area to further inform risk management. It was noted that the UK independent high risk AGP group had prioritised research in this regard in its advice to date and had communicated this to the NIHR AGP task and finish research group and the SAGE EMG sub group chair (Cath Noakes). The current lack of a standardised approach to the science of aerosols makes it challenging to synthesise the available research and there is a need to aim for common standards and approach and clinical research to maximise the benefits of future research. It was noted that there was a need for a study that repeats the non-inferiority trial work done for SARS re FRSM vs FFP3 masks and this was being developed by colleagues in Canada. The Chair commended the excellent work being taken forward by the group.
Ways of working and future work programme
Daniel Kleinberg introduced the paper on potential future topics for group discussion and noted the variety of modelling packs circulated. The complex and dense information they contained was useful for the relatively small number of experts in Scottish Government but the challenge is how to disseminate them more widely and increase their usefulness, making them as relevant and digestible as possible. The group’s advice on this would be welcome. Daniel thanked Tom Evans for agreeing to give a presentation on vaccines to Scottish Government staff. The Chair noted that presentation and the discussion of the salient features of relaxation of lockdown were good examples.
Daniel Kleinberg noted that the secretariat would work to support the group in identifying and sharing international learning and expertise. The Chair noted that he and the Vice Chair had had a very helpful discussion with Camilla Stoltenberg about Norwegian experience. This will be followed up with a meeting to discuss schools and possibly other issues.
It was noted that similar challenges are being faced elsewhere e.g. on schools, testing and approaching the endgame. The key is what is most important to the group and where best to learn – for example, Australia and New Zealand on travel; Brazil and South Africa on variants; Denmark and France on schools and perhaps Norway and Sweden on handling land borders. The group should take a strategic approach focussed on the big questions. While the group could take advantage of experience elsewhere, there was a need to be aware of the dangers of different contexts.