Attendees and apologies
Advisory group members:
- Andrew Morris
- Linda Bauld
- David Crossman
- Graham Ellis
- Tom Evans
- Julie Fitzpatrick
- Jill Pell
- Nick Phin
- Stephen Reicher
- Jacqui Reilly
- Chris Robertson
- Aziz Sheikh
- Gregor Smith
- Devi Sridhar
- Nicola Steedman
- Mark Woolhouse
- Gill Hawkins
- Daniel Kleinberg
- Dominic Munro
- Arlene Reynolds
- Graham Foster
Items and actions
The Chair welcomed members and guests to the 60th meeting of the Group, noting the topics on the agenda. Minutes for the previous meeting had been agreed in correspondence and had now been published, as had an updated Register of Interests.
State of the Pandemic
The Chair opened the discussion, noting that a paper had been tabled on modelling the epidemic in Scotland. The Group were updated on a review of the situation at a National Incident Management Team meeting earlier in the day. Cases had stabilised over the last two or three weeks at around 8,000 a day, 25% PCR, the rest LFD. Hospital admissions had dropped markedly over the same period, with occupancy and ICU also decreased. Deaths had plateaued and were expected to decrease.
Omicron probably developed from a variant first identified in 2020 but the impetus for its surge now is not well understood; more work is needed on what creates the conditions for success of variants/subtypes. Work is ongoing to look at the BA.2 variant of Omicron, which appears to be more transmissible. Early studies show the same effectives of vaccines on BA.2 and no increase of hospitalisations in Denmark suggests the same.
Work continues on evaluating vaccine effectiveness & waning – booster effectiveness remains high for mortality and hospitalisation. Treatments will be important for the future; trials of paxolovid suggest it is very effective. Evaluating the effectiveness of treatments will be important in achieving value for money and EAVE work on effectiveness will extend to antivirals.
Looking at the medium term, future waves were likely, with the size and shape of waves dependent on the nature of the variant, the effectiveness of vaccinations and changes in behaviour. Future variants may not come from Omicron and the next wave may not be as mild; there may be co-circulation of multiple variants. Seasonality may be a factor but we should be prepared for non-seasonal waves due to variants. It may be a number of years before a stable situation is reached.
It will be critical to have robust surveillance and monitoring mechanisms such as the ONS survey. For the future, we need to develop a sustainable approach to testing which provides reliable information on rates of infection, which might include wastewater.
There are differing definitions of endemicity but, generally, the more infectious a virus the quicker an endemic state is reached. Endemicity implies an effective R of 1, with the disease neither growing nor declining in prevalence, though there may be variations in prevalence such as seasonality. It does not necessarily mean that the disease is no longer harmful; malaria is endemic in the tropics but by no means not harmful.
When considering whether endemicity might be tolerated, the impact of the disease is most important. A key metric is the infection fatality ratio (IFR) but there is also a need to bear in mind other outcomes e.g. post COVID syndrome, days at work lost etc. for which exact figures are not yet clear. A comparison with flu, which has a broad IFR of 0.1 % (though it does vary by age), is probably useful. The ONS survey data from serology or population screening gives a better idea of IFR than say PCR tests, which will likely overestimate IFR due to the proportion of asymptomatic infection.
Looking internationally, there are a range of countries comparable to Scotland. Denmark is an interesting comparator; the BA.2 variant is established and flourishing while not doing the same elsewhere; restrictions have been lifted despite Omicron surge. Also instructive to look at New York and the northeast US, where there are high levels of trust and high vaccination. Pfizer are seeking approval for under 5s vaccine.
Public attitude/acceptance remains mostly positive; people are still engaging /adhering. Behavioural changes remain important and a decline in trust would be worrying as it’s important that messages are effective. People were more cautious over Christmas and that made a difference. Agency is an important motivator and it helps if we can confirm to people that their behaviour can be powerful and does make a difference. People’s understanding of the pandemic is also critical to their behaviour – messages that ‘it’s all over’ would affect behaviour in a fundamental way; important that optimism on Omicron is balanced by realism on potential risks of further variants.
Scottish Government Strategic Framework
The Chair welcomed Dominic Munro and noted the slides tabled for this agenda item. The meeting heard that Strategic Frameworks had been in place since Oct 2020 and were a compilation of response strategies covering vaccines, testing, protective measures and other matters. The next Framework would involve a shift in strategic intent – the focus was not about ‘living with Covid’ but about active management; transition involves moving away from legal measures and relying on adaptation of behaviours and physical environments and on health measures such as vaccination and treatments. It would set out the need to be resilient and recognise the potential risks from new variants. There is a need to think about how that is best communicated. The importance of helping to manage COVID internationally was also recognised.
The chair opened the discussion, noting the questions set for the group around testing, how to maintain positive behaviours and our data and intelligence needs.
In discussion, it was noted that a key question would be how we react to variants, which were likely to be the most problematic feature for the next few years. The transmissibility of Omicron emphasised the critical need for very rapid responses to new variants – we were one doubling time (only 2 or 3 days) away from a wave twice as big; luckily Omicron was around the bottom of the range of possible severity. The reaction to Omicron indicated there was scope for improvement, around the imposition and then particularly relaxation of border controls – though we need to consider the need for ongoing surveillance at borders.
There are a number of issues to consider around testing, which is not sustainable at current levels but surveillance needs to be maintained. Proportionality will be important – how much is vital? Surveillance in hospitals particularly helpful – for RSV and flu as well as Covid. For the future, we will continue to need genomic data that LFD does not provide.
An possible solution may be to adapt the system we have of GP sentinel practices for flu. Sentinel surveillance needs investment to improve and scale up – EAVE and huge amounts of testing has enabled us to discover the impact of variants but it needs scale. We need to look at how we strengthen PH systems generally to increase coverage and representativeness of surveillance systems. Surveillance needs for case rates are different from that for new variants – different levels targeted differently.
LFD & waste-water are useful and the best way to achieve value for money is alignment of what is required for Covid with other public health measures – e.g. waste water sampling could potentially also address other issues.
South Africa has decided that isolation is no longer needed for asymptomatic cases – it should be considered whether isolation is now more harmful than the risks of adopting that approach. Culturally, there is a need to change habits of attending the workplace while feeling unwell.
Group members to provide any comments on the Strategic Framework in response to the questions asked to the secretariat by 3pm on Wednesday.
Education and Children’s Issues Subgroup
Recent meetings have looked at changing guidance and mitigations for Omicron have now been lifted. The next meeting will look at face coverings in classrooms and consider testing as part of a discussion of baseline measures. Work was also underway on assembling an evidence paper on wider harms.
Universities and Colleges Subgroup
No change to existing guidance at present, though the ambition in the sector is to get back to face to face teaching. Considering developing a framework, noting precedent in Welsh framework, though there are a diversity of views amongst stakeholders. A separate group is looking at the role of ventilation.
The chair of the subgroup reported that the level of clusters & outbreaks had reduced substantially since the previous meeting in acute and community hospitals. Testing is key to patient placement and infection prevention control is and needs to be seen as an enabler to visiting.
Future of Advisory Group and Deep-dive
The CMO expressed his thanks to the chair and the group for their invaluable advice over the course of the pandemic. He noted that amounted to 60 meetings and over 40 pieces of advice, while acknowledging that meetings are only the tip of the iceberg when considering the input from group members and their contribution to improving Scotland’s response to the pandemic. The way the group had operated had been incredibly useful but there was a need to think about the future in the light of current circumstances and the demands on the group and its members. At this point in the pandemic it is unlikely that there will be a continuing need for regular advice on the science of Covid from, or regular meetings of, the group. Where advice is required, on a new variant for example, a meeting will be arranged but otherwise matters will be dealt with in correspondence and the secretariat will continue to circulate information from SAGE and other sources as usual. The subgroups will continue at present, reporting to the chair of the Advisory Group and the CMO as usual.
Daniel Kleinberg noted that arrangements were in hand for a Deep Dive, which will be held jointly with the Standing Committee on Pandemics and other invitees. The arrangements will be circulated to the group ahead of time once a date had been agreed.
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