- 12 Apr 2021
Attendees and apologies
Advisory Group members:
- Andrew Morris
- Dave Caesar
- David Crossman
- Tom Evans
- Nick Hopkins
- Audrey MacDougall
- Jim McMenamin
- Jill Pell
- Stephen Reicher
- Jacqui Reilly
- Chris Robertson
- Sheila Rowan
- Aziz Sheikh
- Gregor Smith
- Devi Sridhar
- Carol Tannahill
- Cat Carve
- Gabe Docherty
- Matt Holden
- Andrew Rambaut
- Daniel Kleinber
- Marion McCormack
- Niamh O’Connor
- Arlene Reynolds
Items and actions
The Chair welcomed group members and SG observers attending. He welcomed Andrew Rambaut and Matt Holden who joined as observers.
The minutes of the previous meeting have been shared with group members for comments by 9 a.m. on Monday 22 March.
Group members are invited to update their register of interest ahead of its upcoming publication.
State of the pandemic
The group was given an update on the state of the pandemic. R has increased and is now at 0.7-1.0. Increased testing is now available and schools have reopened. Early analysis of data suggests, that due to the increased transmissibility of the UK variant, there may be increased transmission within school and Early Learning and Childcare (ELC) settings.
Work is ongoing to agree naming conventions for new variants of concern. The recent availability of allele specific primers for specific variants of concern/under investigation have presented the opportunity to identify new variants earlier when cases are picked up, prior to receipt of full genomic sequencing of these cases.
Recent evidence suggests an increase in interactions in adults aged 30-50 and between children of school age. Interesting patterns are developing between these age groups.
The Chief Medical Officer and Chief Scientist outlined the creation of a sequencing service in Scotland to support the pandemic response as well as providing long term benefit to sequencing in Scotland. This will significantly increase capacity for this type of service. The Chief Medical Officer noted the invaluable work undertaken by these teams throughout the pandemic response.
Early data is showing a slight uptick in cases. This remains small, however, it will need to be closely monitored as we proceed with changes to restrictions in Scotland. In addition, there are concerns about growth of other variants of concern in neighbouring European countries. The potential slowdown of vaccination given recent supply announcements was also acknowledged by the Group. An additional variant under investigation in New York has been identified. The progression of this variant in New York and other emerging variants will need to continue to be closely monitored.
Early data from schools and Early Learning and Childcare return is hard to interpret, including as a result of the increased amount of testing taking place. There are signals showing some larger clusters of cases developing rapidly and this is a more common occurrence than it was when schools were open in the autumn term. The approach to move ‘fast and hard’ once cases are identified continues to be important. Group members noted this while recognising the impact of disruptions to children’s learning. The volume of testing in schools and in the community has increased significantly given the increased testing provision now available in both these settings.
The uptake of vaccinations has been very high and there are positive effects from this being seen in hospitalisations. Increased transmission does present a real risk of new mutations appearing.
Group members asked whether it is possible to control data for increased testing. This is challenging as there are inconsistencies in how the data is recorded. Those who test positive after a lateral flow test continue to be encouraged to get a confirmatory PCR test. In paediatric cases in particular uptake of confirmatory PCR tests is not as high as it could be. It may be possible to obtain more granular data on the proportion of asymptomatic cases among positive cases.
The majority of 50-59 year olds have not yet been vaccinated. The proportion of this group that is vaccinated will need to be considered given the uptick of cases and the proposals to ease restrictions in coming weeks. Early data on contact patterns is also showing that those with underlying health conditions who are vaccinated have increased their contacts compared to those who are not yet vaccinated.
No difference in contact patterns was noted for those without underlying health conditions.
Levels of compliance are likely to be different among different groups by age, occupation, ethnic minority etc. This has the potential of creating pockets of the country where case numbers are much higher than others and exacerbating existing inequalities in these areas. It could also lead to social blaming where the driver is not motivation but capacity.
Group members acknowledged the updated timetable for easing restrictions published earlier in the week. From a behavioural science perspective it was noted that there is a risk these are perceived as absolute, rather than contingent on continual improvements and this is reflected in the media coverage of the timetable. Group members asked about any indications of changes in compliance from behavioural data and changes in the perception of risk. Pictures of gatherings in parks in Edinburgh and Glasgow could suggest that the perception of the threat from covid has diminished. The current decreases in hospitalisation and ICU data provide optimism but we should remain cautious and maintain adherence to restrictions and NPIs. The Group noted its concerns that a return of international travel presents a real risk of the importation of new variants in the future.
The Group was shown latest scenario planning modelling from the Scottish Government. These show expected changes to R, case numbers and hospitalisation based on different variables including vaccine impact, compliance and new variant impacts. A lot of uncertainties are acknowledged, however the continued need to caution is reinforced by these. A recent study in the New England Journal of Medicine found that a two-dose regimen of the Oxford-AstraZeneca vaccine did not show protection against mild-to-moderate cases of the B.1.351 variant or so-called South African Variant.
The impact of vaccinations on deaths should not be understated. Data thus far is extremely encouraging from all vaccines in use. Models all show that there will be an additional wave resulting from relaxation, although the scale and impacts of this wave is the unknown. We have agency here. The protection from the first vaccine dose is important but it is crucial to get the second dose to ensure JCVI groups are fully protected.
The Group was made aware of ongoing work on trying to characterise first dose vaccine ‘failures’ and to understand first dose vaccine waning. The Group will be shown data on these when they are available.
- monitoring behaviour change across age groups will be important
- welcome sequencing announcements, especially for vaccine resistant variants
- monitoring schools and early years settings important, noting impact of closures
- need to strike balance, we must not be complacent
- international travel a significant risk
- inequalities should continue to be carefully considered by government
- praise for the analysis teams in government
The Group was given an overview of data from PHOSP-COVID, funded by UKRI. This is the largest cohort study of post-hospitalisation Covid and it has found there is still substantial morbidity six months after discharge. There is uncertainty about phenotypes but ongoing respiratory, cardiovascular, neurological symptoms. Those most at risk are female, middle aged, white. The extent of morbidity in some has led them to change employment. A pre-print on this will be released early next week. An additional call from NIHR will be coming out soon, focussing on primary and community care and interventions and models of care. Funding calls are all looking at specialist long covid clinics. These do not exist yet in Scotland and there may be need for engagement on this with funders.
A task and finish group is looking at long-covid HIS-SIGN RCGP guidelines. Feedback from GPs currently is that they are not being overwhelmed by long covid cases, though there may be hesitancy to visit a GP given the ongoing pandemic. Data on the impact of long covid on employment data may be being obscured by the current furlough scheme. Data published in Nature from the ZOE study is consistent with what has been presented here. Those hospitalised have a much poorer trajectories – more severe long covid in those with more severe disease. Treatment options for long covid are currently very limited.
A separate study analysing disruption to the healthcare system during the pandemic shows there are enormous disruption effect in A&E, elective and acute care. Disruptions are being seen across health boards and the NHS is not currently running as normal. Emphasis on the importance of getting the NHS up to speed given the harm that disruption will be causing.
The Group was updated on the last SAGE meeting. SAGE is now meeting fortnightly.
Vaccines, mutations and new variants
The Group was given an update on mutations and new variants. These are being identified increasingly often globally. Three original VOC have mutations in common and are being seen to take on other mutations of VOC suggest something is changing in the adaptive landscape. There is a tendency to call new variants more frequently and not all are as concerning as each other. Notable variants B1.525 (Nigeria and West Africa, and many other countries) this has the E484K mutation and a few others. New York variant (B1.526) has two branches with different spike mutations of potential antigenic importance. The current debate is whether there is a substantial difference in transmissibility of B.1.1.7 and these two variants.
There is reportedly a large number of B151 cases in France but it is not known whether these have been identified through targeted sequencing or surveillance. France is a significant potential source of imports from the South African variant and is not currently on the UK red list. P1 has a sub-linage in Italy P1.1 which is notable as it makes Italy the second largest country with P1 but the epidemiology of this is unclear and needs further investigation.
In Scotland most of the sequencing has been done to provide confirmation of VOC. Surveillance sequencing in areas where these were picked up has been undertaken and so far these have not picked up any unlinked cases from these. This suggests limited spread but also highlights the importance and value of additional sequencing. There are now requests to sequence cases from vaccine failure. Alongside sequencing, serological investigations are needed to understand what has occurred in these cases. The future will be marrying up genomic data with detailed information about patients in order to understand the demographics.
Regarding travel, Group members noted that the situation we are now in with red list countries is similar to the situation in February 2020 where the focus on preventing the importation of cases was on arrivals from China rather than importation from Europe.
Group members asked whether there are any indications that we are reaching structural/biological saturation. Non-spike mutations seemed to be spreading rapidly in the US. We are seeing similar constellations of patterns in lineages. We do not appear to be reaching saturation. Some sites will be key and some substitutions will be more effective than others. There will be some variants that are more successful in some hosts than others. As we go into a time of high vaccination this will not be as much of an advantage as antigenic escape. Current variants may well not be the ones to achieve antigenic escape. In a high vaccinated environment those mutations could come up quite easily. Need to understand what it is in B.351 that gives it that effect. Good news – study shows vaccine for B.351 would give protection for ‘older’ variants. Evidence does suggest that antibody mediated effect is attenuated at a level where you might change vaccine composition using other models of antigenic change and immune escape.
A study in Lancet a found natural immunity seems to wane more rapidly in older populations.
The Group noted the challenges that the current increased transmissibility of the B.1.1.7 and new variants could have for mitigations and reflected on whether a more rigid application of 2m physical distancing and NPIs will be required once non-essential settings reopen.
Current variants don’t tell us much about what will happen in the future. We don’t yet understand why they are evolving and circulating at the moment. It is not clear if this is a response to current levels of vaccine or seroprevalence. Variants of concern with the same mutations or sets of mutations are to be expected. What we could not predict is that all this has occurred simultaneously, many times over the past months. We would not have predicted getting the same set of mutations across various genes in many different lineages.
There continue to be many challenges in responding to the pandemic and it is important to stress that despite significant improvements from the vaccine rollout, challenges will remain. The group noted the need to restate this.
- the update on variants was very helpful and will be revisited at future meetings
- huge uncertainty about the future of variants remains and what we have observed to date may not tell us much about what will happen in the future
- it is possible future variants will not be much more transmissible than B.1.1.7 and that antigenic escape will be the route to selective advantage with the increase of vaccinations
- borders remain extremely important and an approach to red list countries will not keep variants out in perpetuity
- vaccines updates – when will we have biomarkers or correlates to indicate vaccine escape
- despite the successful of the vaccine rollout, significant uncertainty remains. Complacency should be avoided but we must also recognise amazingly high uptake and tremendous efforts with mass rollout
Schools – Difficult to interpret so far what the effect of reopening has been. Concerns remain high in school staff. Challenges such as maintaining 2m distancing will be difficult to manage if required when all pupils return. Opportunities to learn from England where schools are back.
Testing – The subgroup spoke about possibility of using novel testing in those who are still PCR positive but not infected. A subgroup of the testing group led work on the establishment of a sequencing service. [Redacted].
Nosocomial Review Group - Last week the group considered a report on lesson learned from hospital outbreaks. Multiple factors affecting risk, commonly problems of mask wearing adherence in patients, physical distancing adherence and movement of staff and patients within the hospital. Continued focus on behavioural insight work being led by a sub group of CNRG which is ongoing. Advice was also given on hospital visiting guidance. SAGE EMG has also been asked by CNRG what more can be done to optimise hospital ventilation systems. The Health and Safety Executive have completed a report of inspections in hospital across the UK and the recommendations from that are being considered by CNRG. CNRG assessing the evidence on an on- going basis to inform updates to the UK IPC guidance related to occupational health risk to healthcare workers and type of mask worn with cases of confirmed and suspected COVID-19.
The Chair noted the subgroup updates will be moved up the agenda at the next meeting.
Lots of interest in international learnings. Group members will work with the Secretariat to identify how these can best be supported.
The Chief Medical Officer thanked group members for their huge contribution and support over the past 12 months of the pandemic.