- 6 Dec 2021
Attendees and apologies
Advisory Group members:
- Andrew Morris
- David Crossman
- Linda Bauld
- Graham Ellis
- Tom Evans
- Nick Hopkins
- Audrey MacDougall
- Jim McMenamin
- Stephen Reicher
- Jacqui Reilly
- Chris Robertson
- Aziz Sheikh
- Gregor Smith
- Devi Sridhar
- Mark Woolhouse
- Cat Carver
- Gabe Docherty
- Graham Foster
- Nick Phin
- Dominic Munro
- Daniel Kleinberg
- Marion McCormack
- Liz Sadler
- Niamh O’Connor
Items and actions
The Chair welcomed group members to the 55th meeting of the Covid-19 Advisory Group. He also welcomed Dominic Munro, Liz Sadler, Marion McCormack and Niamh O’Connor from the Scottish Government.
The Chair noted the Scottish Government Cabinet meeting next week which will consider the current state of the pandemic and whether additional measures should be introduced.
The Covid-19 Advisory Group was invited to consider the current state of the pandemic, as well as:
- where is the epidemic in Scotland and the UK, compared to Europe?
- it appears the recent increase in Europe is driven by Delta but does the group agree?
- what is the expected direction of travel for Scotland?
- what impact could additional NPIs have on healthcare strain and other relevant harms in the course of the pandemic in the coming months?
State of the pandemic
The group were shown scenarios for the autumn and winter, drawing on medium term projections. These can also be described as a series of plausible futures. Factors considered include the risk of new variants, reductions in compliance, and vaccine waning. The modelling includes assumptions for influenza and RSV. Pressures on the health services are stark when RSV and influenza are also taken into consideration. This highlights the critical importance of completing initial vaccinations and boosters given the impact of waning. The group considered the high numbers of influenza A and B in the models, noting that the southern hemisphere has had very low levels of influenza again this year. There is considerable uncertainty in the direction of future modelling, though it was noted that while cases and subsequent hospitalisations may increase or decrease, we are unlikely to see surges in Delta cases similar to previous waves.
Contact surveys show rising contacts in recent weeks, notably contacts in workplaces. Cases rates among adults show a decrease in cases in the over 65s and an increase in those aged 25-64. Among children the biggest rises are among primary school children, with a slow rise in secondary school children. Data on hospital admissions show these are larger in those aged 40-65. Among those in hospital over the past two weeks (1-15 November) over half of those admitted were over 65 with the majority belonging to at least one risk group. The group noted the encouraging signs of a downturn in cases in older age groups, a downturn which again highlights the effectiveness of booster doses. Data from UKHSA shows a reversal in waning in vaccine protection in oldest cohorts receiving booster doses. Data on vaccine booster uptake from EAVE-II for adults over 16 shows a good uptake in those aged 65 and over. The latest data from the REACT study will allow us to trace third dose breakthroughs.
The group was optimistic but cautious and highlighted the importance of maximising booster uptake in those who are eligible, particularly in those who are most vulnerable. It noted the upturn in cases in children, the uncertainty around influenza, the possible breakthrough infections in those with 3rd doses (incl. boosters) but also the decrease in the severity of illness as a result of vaccination.
Analysis on the AY4.2 variant is showing in the unvaccinated a change in the proportion of the unvaccinated who require hospitalisation. This data should continue to be monitored but also underlines the importance of maximising booster uptake in the population. There are initial signs in some of the other parts of the UK that cases and hospitalisation rates are rising, possibly linked to the rising wave of cases in Europe. The group was shown data comparing the UK with EU/EEA countries. There is a sharp take-off of cases in a number of European countries. Vaccine uptake rates do show that there is almost an inverse correlation between coverage and covid rates, though there are some countries with high vaccine coverage that are also seeing spikes in the number of infections. Group members considered the current patterns in Europe, commenting that it is likely Europe is several weeks behind the UK in terms of their level of Delta variant. In comparison, the Delta wave occurred primarily in the summer in the UK and during a period of high vaccine uptake which may explain the surges being seen in other countries where the timing has been less fortunate. This is likely the case though group members stressed it is not a certainty.
The group were given an overview of the current Scottish Government approach and measures that are being considered by Ministers, including measures to increase vaccination uptake and the possible widening of the certification scheme. The Scottish Government published its latest strategic framework this week, with a strategic intent to: “to suppress the virus to a level consistent with alleviating its harms while we recover and rebuild for a better future". The timing of any changes in measures will be important, taking into account possible changes in R as well as the festive season. Group members noted the challenges in using R number as a basis for policy in the current context, notably in balancing COVID-19 and non-COVID-19 harms. The booster vaccine programme is recognised as being the most important intervention for the government at this time.
The Scottish Government has published the updated evidence paper that will used in considering changes to the certification scheme. Group members also noted a systematic review and meta-analysis published in the BMJ, noting the impact of mask-wearing and other interventions but in particular the paucity of research into behavioural science surrounding mitigations.
The group noted that measures like certification should be considered as a means to an end and like all interventions, this should be designed with a specific objective in mind. The impact of measures such as certification is not immediate as there is a lag in the time for individuals to take up vaccination and receive their vaccine certificate for this (2 week lag post-vaccination). Vaccine uptake has the greatest impact on cases, transmission and subsequent course of disease. If measures such as certification increase uptake this will be extremely positive, though the specific effect on transmission may not be significant. Even a seemingly small difference in vaccine uptake can make a significant difference on cases and hospitalisations. It was noted that while the overall impact of individual measures may be marginal, these should be considered as part of a wider package of measures, with the Scottish Government aiming to maintain R at or below 1. The impact of measures, including certification, in maintaining awareness of the risk of covid was also noted.
Group members agreed that increasing vaccine uptake will have a significant impact. Behavioural science suggests possible heterogeneous effects of this scheme on uptake. In groups that could be termed ‘vaccine indifferent’ certification could be an effective push to take up vaccination. Among those who are ‘vaccine hesitant’, there is a risk that individuals may not take up the vaccine following the introduction of tools such as certification. In groups who may have a distrust in authority, certification can increase this distrust. The importance of engagement with the public to encourage vaccine uptake and of ensuring accessibility of vaccines was emphasized. For boosters, engagement with the public has flagged difficulties in accessing vaccination centres in some areas and the timing of vaccinations around the festive period which may see individuals delaying their boosters to the New Year. There is also scope for improved public communication on face masks and the importance of working from home.
In discussing NPIs, group members commented that the framing of measures as restrictions, rather than protective and supportive measures can impact the public’s perception of these. The framing of measures should also emphasise the role of these in protecting the collective should be reemphasized.
- current situation in Europe – it is likely Europe is several weeks behind the UK in terms of the level of the Delta variant which is driving the current high case numbers in many European countries. This is likely to be the case but is not a certainty. The modelling is therefore most likely to be correct to suggest that the most likely outcomes are a rise then fall; a fall; or slower rise, with sudden growth like that in Europe not predicted
- vaccines - the group highlighted the importance of maximising uptake of boosters as well as increasing uptake in first of second doses of vaccines. Vaccines are the most effective measures but should be considered as part of a basket of measures
- NPIs - with any non-pharmaceutical interventions (NPIs) it is important to be clear what these are trying to achieve and why. The group noted the importance of strengthening and increasing adherence to measures which we know work. The group endorsed papers 2c and 2d
- communication – group members noted the importance of the way measures are framed. Framing measures as protections rather than restrictions may help to remove negative some associations of these with lockdowns. The framing of measures should also emphasise the shared, rather than the individual benefit of these
The Chief Medical Officer thanked the group for the rich discussion during the meeting.
Universities and colleges
The group will hold its next meeting in the coming week. Recently, conversations have taken place with stakeholders and have raised challenges such as the level of face-to-face teaching that is being done and also being planned for by the sector.
Education and children
Schools have the same mitigations now as they had last term. There have not been changes to these. The subgroup is now looking ahead to longer term harms from the pandemic which will feed into covid recovery discussions.
On face coverings in schools – direct comparisons with England are difficult to make. There is good public heath rationale for the use of mask wearing as a mitigation in these settings. The subgroup also takes into consideration the wider harms from this mitigation. The possible used of clear masks was raised, particularly for use in early learning settings. The Chair subgroup noted this and commented that this may be considered by the subgroup in future discussions.
The COVID Nosocomial Review Group met last week. The group observed that whilst the number of clusters and outbreaks remain lower than previous waves, half of current COVID-19 clusters are in care of the elderly specialties, which has not been seen since the first wave. These facilities include community hospitals and it was noted that booster vaccine uptake in these settings is key. It also noted that high contact numbers have been observed in some of the clusters in hospitals and a key theme from the lessons learned from recent outbreaks was the impact of system pressures and occupancy on contacts. Other factors for current focus are adherence to admission testing and serial testing of inpatients at five days, and patient and visitor adherence to mask-wearing in healthcare settings.
A future preparedness paper will be discussed at the next meeting.
The subgroup met earlier in the week, discussing the longer term future of testing. This is part of wider four nations discussions about the future of testing. Among the points covered were the possibility that lateral flow testing would play a greater part in the testing strategy, with a decrease in the scale of PCR testing carried out. The subgroup considered the way this would affect current indicators used in the COVID-19 response. Changes in the approach to testing would reflect changes in the stage of the response from the emergency to the endemic stage and a change from testing to reduce prevalence, to testing as a means of surveillance. It was noted that any reduction in PCR testing data would also have knock on effect on our ability to determine vaccine effectiveness.
Any changes that would see a greater reliance on lateral flow tests (LFTs) should draw on studies of testing behaviour, including those that were funded by CSO. Data is available from PHS on the proportion of positive LFT that go on to book confirmatory PCRs. Data is available on the use of LFTs during mass events pilots and this showed the possible limitations of relying on LFTs in situations where a positive test would mean being unable to participate in a given event (e.g. concert). Issues to consider with future use of LFTs must include consideration of how people take LFTs and report these.
The Secretariat proposed the 16 December for the date of the next meeting, though this is subject to change.