- 22 Sep 2021
Attendees and apologies
Advisory Group members:
- Andrew Morris
- David Crossman
- Tom Evans
- Nick Hopkins
- Audrey MacDougall
- Jim McMenamin
- Stephen Reicher
- Jacqui Reilly
- Chris Robertson
- Aziz Sheikh
- Gregor Smith
- Devi Sridhar
- Nicola Steedman
- Carol Tannahill
- Mark Woolhouse
- Cat Carver
- John Logan
- Humza Yousaf
- Richard Foggo
- Daniel Kleinberg
- Arlene Reynolds
Items and actions
The Chair welcomed group members and the Cabinet Secretary for Health and Social Care who attended the first part of the meeting. He also welcomed [Redacted] who attended as observers.
Reflections from the Cabinet Secretary for Health and Social Care
The Cabinet Secretary thanked the Chair for his welcome. He thanked the C-19 AG for the expertise and advice it has provided to the Scottish Government throughout the pandemic.
The Cabinet Secretary and the C-19 AG then discussed the balance of easing restrictions and a return to a greater degree of normality, whilst supporting the continued compliance with NPIs where recommended.
Many challenges continue, including vaccination uptake, the risk of new variants, border policies and the impact these can have on possible importation of variants, and preparations for future pandemics.
Group members noted the very high vaccine uptake, especially in older and more vulnerable groups. The importance of continuing to strive for the highest possible uptake was emphasised, with an illustrative example given that a programme that has 96% coverage leaves double the proportion of unvaccinated (4%), compared to one that achieves 98% coverage and leaves 2% unvaccinated.
Commenting on hospital admissions, group members noted that the majority of those coming into hospital are unvaccinated, although some admissions are in people who have had one or both doses.
Unvaccinated individuals are of greatest concern. Observations from hospitals are that these are also often those for whom English is not a first language and those from minority ethnic backgrounds. This highlights the importance of continued engagement across communities to encourage vaccine uptake.
Group members briefly discussed the issue of booster vaccines, acknowledging the difficult ethical decisions to balance given the large proportion of the world still unvaccinated. In low-income countries there is low vaccine supply. Whilst recognising the contribution that donations make in these countries in the short term, there is a much greater challenge to increase domestic manufacturing capacity in low and middle-income countries.
Epidemiologically there are still uncertainties about the trajectory of the pandemic. The group considered the role that NPIs are continuing to play domestically, alongside the pressures Scotland and other countries face. Leading issues include the use of masks, how long to require these for, who should use them, and what settings they should continue to be used in; health services, the pressure on hospital staff, the risk of burnout and exhaustion and the importance of factoring all these into capacity planning; decisions on the vaccination of children and young people and what mitigations to keep in place for the unvaccinated.
The Cabinet Secretary engaged group members on these issues, recognising the important challenges these present. The issue of mitigations is one where the Cabinet Secretary noted the importance of ensuring measures are proportionate and consistent. On the subject of the health workforce the Cabinet Secretary recognised the need to approach the remobilisation of the NHS with honesty, with staff wellbeing at the heart of this.
The Cabinet Secretary and the group noted the ongoing research into long covid. While this is likely to be several different syndromes, it is not yet understood how to treat these.
In providing support to those suffering from long covid syndromes, it is important to take equity considerations into account, particularly for similar conditions where the same level of resource may not be provided. It is also important to ensure that support is available across regions and beyond the Central Belt of Scotland. A frustration of patients can be having to go to multiple appointments with different specialists in different locations, though if these specialists were to be pooled in clinics at the same location they would no longer be providing the care for conditions and patients they currently support.
Looking at behavioural interventions, the group noted that levels of adherence to restrictions and guidance have remained high, with the public continuing to follow these. Observing early data from England, which eased some restrictions, such as the closure of nightclubs before Scotland, group members noted that there has not yet been an associated increase in cases associated with this. It may be the case that less people are attending these because of a continued desire to be cautious.
Group members noted that a key question is how to support individual decision making and responsibility to empower individuals to make informed decisions about their level of risk. One example could be by indicating how well-ventilated different spaces are. The discussion concluded that it remains important to continue to have open, honest communication with the public.
The Cabinet Secretary noted that the Scottish Government is actively considering preparations for the next pandemic, alongside its continued response to the covid-19 pandemic. These preparations will include the creation of a standing committee on pandemics, focussing on ensuring the country is as best prepared as possible for future pandemics. This committee will exist alongside the C-19 AG, ensuring the Scottish Government continues to receive advice to support the acute phase of the covid-19 response, whilst in parallel preparing for the future.
The Cabinet Secretary thanked group members and left the meeting.
State of the pandemic
The possibility of waning immunity was discussed at SAGE. A summary paper on what is currently known about long covid was also circulated as part of SAGE papers, recognising the wide variety of syndromes that could make this up.
Group members noted the discussion of VOCs, commenting that it is possible that future variants of concern probably already exist, though planning for these continues to be challenging. It is important to plan for the arrival of new variants. As noted by SAGE, border measures will delay but not prevent importation.
The group noted comments in the media regarding SAGE modelling of possible future outcomes, recognising that models, and their limitations, may not be understood to be as such in the media, but instead treated as predictions.
Seroprevalence studies last summer were showing much lower levels than observed now. Vaccines have been incredibly effective against the current variant. Vaccines may be dampening transmission enough that they prevent large clusters among those double vaccinated. New Zealand and Australia are planning to vaccinate their population to at least 80%, before moving to a similar policy approach to the UK.
The current situation is positive and has improved more rapidly than initially expected. However, the delta variant is still circulating and transmitting. The group considered whether the continued transmission of Delta at low levels could prevent the emergence of vaccine escape variants.
Contact levels in the population have remained fairly low. This does show there is still room for significant increases in contacts which could lead increased transmission risk. The messaging around risk is critical, continued caution is important, the virus is still here but messaging on this does need to be balanced to reflect the progress made and that the sacrifices people have made have been worthwhile.
The group was shown the latest Scottish Government modelling, due to be published on 5 August. R in Scotland is now between 0.7 and 0.9. Qualitative data has shown that a large number of contacts are still outdoors. Waste water data still shows higher levels of infection than testing data. The reasons for this are being investigated.
The group noted the latest Beyond Level Zero announcements from the Scottish Government this week.
International update – The group noted the different approaches internationally for vaccine certification. Certification is still being considered by the Scottish Government, as noted by the First Minister in the Beyond Level Zero announcements.
Universities and colleges – The announcement of vaccination of 16-17 year olds was noted by the subgroup and advice has been tailored accordingly. The subgroup remains concerned about the start of term, and the advice calls on institutions to apply a greater degree of caution. Concerns focus particularly on the geographical mixing that takes place at the start of term.
Education and children – there has been a lot of engagement with stakeholder bodies. The school-age population will be largely unvaccinated when schools return. Advice has been for a change in self-isolation policy, with a negative PCR required before close contacts return to school. The advice on other mitigations has been to maintain these for the first six weeks of term. It is likely there will be a greater proportion of infections in the school-age group following the return to school, particularly given the high vaccination coverage in the rest of the population. The education subgroup will be reconvened at the end of August to consider data from the first few weeks of the return of schools. Future work may include a reflection on pandemic preparedness in the education sectors and lessons learned. The continued alignment of subgroups with the main advisory group will continue to be important.
Nosocomial subgroup – two papers were shared with the group. The first paper related to the use of FFP3 equipment in healthcare settings. The second paper was on physical distancing in healthcare, which was commissioned with a particular focus on balance of harms.
Paper 1 – this considered whether wider use of FFP3 masks is warranted. The nosocomial infection risk is currently very low and the CNRG endorsed the current guidance. The subgroup also noted a systematic review on this topic by an Australian group of researchers and there has also been work on this area by the Norwegian Defence establishment. The group noted the concerns that some healthcare staff may have with regards to the level of PPE used, even when patients are deemed to be very low risk. The group noted the paper and the Chair thanked the CNRG for all the work they have done.
Paper 2 – the physical distancing commission considered physical distancing in healthcare settings, given the impact this is having on the NHS ability for services to be mobilised in hospitals and healthcare settings. The paper looked at whether it would be possible to reduce the physical distancing to less than 2m in support of balancing harms. The group considered the latest evidence on physical distancing in healthcare settings, including the update to the international IPC guidance from the WHO published in July 2021. This confirms that where possible maintaining at least 1m in healthcare settings and increasing this where possible is important. The subgroup acknowledged that we are now in a different phase of the pandemic with much higher vaccine uptake. Community transmission is still high and the subgroup was mindful of the upcoming winter which may increase risks. Distancing is an important measure in the hierarchy of controls. The subgroup acknowledged there was little evidence to base a decision on, there was some pilot study work undertaken in outpatient settings have taken place in decreasing distancing from 2m to 1m and there was not significant increased risk reported from this. It was noted, this advice focusses on selected settings and areas of healthcare where this may be considered as part of risk assessment, rather than any change to inpatient ward areas. Risk assessment using the hierarchy of controls is a continuing requirement in a health and care environment context for IPC. It also noted that consideration must be given to the needs of those who are shielding or immunocompromised in making these risk assessments. It should also be noted that patients with multiple contacts with health services may be higher risk so consideration of this is also important. The group noted the advice. They noted the limited available evidence for the Delta variant which is more transmissible than the Alpha variant. A caveat on this will be added to the draft advice and the note circulated in correspondence.
It was noted that the nosocomial subgroup (CNRG) have now formed a subgroup on future preparedness.
Testing – A very brief update was given, noting that the main issue for this group currently is how the public health response changes upon identifying particular mutations.
Group members noted the uncertainty of the next few months and the importance of considering the factors that will continue to impact on the course of the pandemic.