Last updated 05 May 2020
This detailed, extended blogpost covers frequently asked health questions around coronavirus (COVID-19). Knowledge in this area is rapidly evolving and there are still many unknowns. We will therefore update this blog when necessary. For ease of navigation, links below take you to the relevant section of the blog:
What is SAGE?
The Scientific Advisory Group for Emergencies (SAGE) provides scientific and technical advice to support government decision makers during emergencies. The UK Government publishes the latest available evidence provided to SAGE. This includes information on current understanding of COVID-19, behavioural and social interventions, behavioural science, self-isolation and household isolation, mass gatherings and modelling on the virus.
On 4 May, the UK Government published a list of the members who provided input at SAGE and a number of other groups such as the Scientific Pandemic Influenza Group on Behaviours.
What is the Scottish COVID-19 Advisory Group?
A COVID-19 Advisory Group has been set up by the Scottish Government to provide scientific analysis of the impact of COVID-19 in Scotland. The Group is chaired by Professor Andrew Morris, Professor of Medicine at the University of Edinburgh and Director of Health Data Research UK.
What is the difference between coronavirus, COVID-19 and SARS-CoV-2?
Each of these terms are often used interchangeably but they are actually quite distinct. Coronaviruses are a family of viruses that range from the common cold to MERS (Middle East Respiratory Syndrome) and SARS (Severe Acute Respiratory Syndrome).
SARS-CoV-2 stands for Severe Acute Respiratory Syndrome Coronavirus 2 and is a new type of coronavirus. It is this specific virus which causes COVID-19, the name given to the resulting disease.
How transmissible is SARS-CoV-2?
The transmissibility of a virus is measured by the reproduction number, R. This measures the average number of new infections generated by each infected person. When R is greater than 1, an outbreak is self-sustaining unless control measures are introduced to slow or stop transmission. When R is less than 1, the number of new cases decreases and eventually the outbreak will stop.
When a population is unaware of a new virus and everyone is susceptible, the reproduction rate is constant for a period of time as it spreads unimpeded. This is called the basic reproduction number or R0.
There are differing estimates of the basic reproduction number for the virus that causes COVID-19, SARS-CoV2. These range from 1.9 to 6.5. However, most estimates – including the modelling which is being used to inform the UK response – estimates that basic R0 is between 2 and 3. This means that on average each infected person will pass on the virus to another 2 or 3 people.
The reproduction number does not just reflect the characteristics of the virus, but instead it is determined by a combination of biology, environment and behavioural and social factors. As a result, it may differ between areas.
At the daily news briefing on 16 April 2020, Sir Patrick Vallance, the UK’s Chief Scientific Adviser, stated that they are confident the R number has now dropped below one. He estimated it could be between 0.5 and 1. On the 30 April the R value was estimated as being between 0.6 and 0.9.
The Scottish Government’s document framework for decision making – further information estimates that about 26,000 people in Scotland are infectious (5 May 2020) and that the R number is likely to be between 0.7 and 1.0 in Scotland.
How is the virus spread?
The main way the virus spreads is through respiratory droplets expelled when someone coughs, sneezes or speaks.
Many people with COVID-19 experience only mild symptoms. This is particularly true at the early stages of the disease. The risk of catching COVID-19 from someone with no symptoms at all is very low, but it is possible if they have, for example, just a mild cough and do not feel ill.
How long does the virus survive on surfaces and fabrics?
It is not certain how long the virus that causes COVID-19 survives on surfaces, but it is thought to behave like other coronaviruses. Studies suggest that coronaviruses (including early research on the COVID-19 virus) may stay on surfaces for a few hours or up to several days. This may vary under different conditions, including the type of surface, temperature or humidity in the environment.
What is the incubation period of the virus?
The incubation period is the time between catching a virus and beginning to have symptoms of the disease. Most estimates of the incubation period for COVID-19 range between 1 and 14 days, most commonly around 5 days. This is broadly in line with other coronaviruses such as MERS (5.8 days) and SARS (4.7 days). Research findings are constantly being revised as more data becomes available.
What proportion of people will need to go into hospital and critical care?
The COVID-19 Scottish Primary Care Hub Triage Guide notes that around 20-30% of people with COVID-19 will require hospitalisation and around 5% will have a poor outcome such as Acute Respiratory Distress Syndrome (ARDS), shock, renal failure or cardiovascular collapse and require admission to critical care.
A report on the features of 16,749 hospitalised UK patients with COVID-19 reported that 17% required admission to high dependency or intensive care units.
An audit of COVID-19 patients in critical care in England, Wales and Northern Ireland found that half of people requiring critical care did not survive.
The SPICe Spotlight blog Coronavirus (COVID-19) in Scotland – latest data contains up-to-date figures on admissions to hospital and Intensive Care Units in Scotland.
What is the fatality rate of the virus?
There has been much discussion about just how fatal the virus is. The most common way for this to be measured is by calculating the ‘case fatality rate’ (CFR).
The CFR refers to the proportion of all cases which result in a death. However, without knowing how many people in a population have been infected, it is not possible to calculate an accurate CFR.
The case fatality rate in the UK/Scotland is not known because we do not know how many cases there have been, only those that have been tested. It is likely to be some time before an accurate CFR is known for Scotland. The CMO has said that the official infection figures were a “very significant underestimate”. This may lead to an overestimation of the CFR if the current data is used.
A review of case fatality rates around the world shows large discrepancies in reported figures (ranging from 0.19% to 15.56%) indicating significant uncertainty about the exact rate. These will be heavily influenced by testing policies and available healthcare.
Nevertheless, UK modelling of global data has estimated 1% of infected people will die.
Why do people respond differently to the virus?
It is not yet clear why some people have very different experiences of the virus. Some people have no symptoms at all, whereas other normally healthy people can become seriously ill. A number of suggestions have been put forward to explain this. This includes differences in people’s immune system response, genetics and lifestyles.
According to an analysis of death certificates in England and Wales by the Office for National Statistics (ONS), the following characteristics were associated with an increased death rate:
- Gender – the death rate amongst men was twice that of women.
- Age – the death rate increases with age and those aged 80-84 years made up the largest proportion of deaths.
- Pre-existing conditions – 91% of people whose death involved COVID-19 had a pre-existing condition. Most commonly, this was heart disease, but other conditions included dementia/Alzheimer’s disease, chronic lower respiratory disease, influenza and pneumonia, and diabetes.
A report on 16,749 hospitalised UK patients with COVID-19 found that 47% had no documented reported comorbidity (pre-existing conditions).
A high proportion of illness and death has also been observed in black and minority ethnic groups. The UK Government has commissioned Public Health England to look into the link, starting with recording cases and deaths by ethnicity.
How many people have died?
The number of recorded deaths from COVID-19 in Scotland is changing each day. Data on deaths is being updated daily on SPICe Spotlight.
Up until 8 April, only figures for those who had died with a laboratory confirmed infection with COVID-19 were being published by the Scottish Government. However, National Records of Scotland (NRS) is now publishing weekly reports of all deaths where COVID-19 was mentioned on the death certificate. This will allow for the inclusion of deaths of people who were not necessarily tested for COVID-19.
The NRS publications provide a breakdown of the distribution of deaths across the sexes, age groups and by location (care home, home, hospital, other institution) and by health board area.
These figures show, as at 15 April, the greatest proportion of deaths have taken place in the 75-84 age group. They also show a greater proportion of deaths were amongst men and occurred in hospital. A further analysis of the data shows NHS Greater Glasgow and Clyde and NHS Borders have the highest death rate per 10,000 population (please note this is the crude rate and has not been adjusted for age distribution).
Have there been more COVID-19 deaths in more deprived areas?
On 1 May, the Office for National Statistics (ONS) published deaths involving COVID-19 by local area and socioeconomic deprivation for England and Wales. This showed that people living in more deprived areas have experienced COVID-19 mortality rates more than double those living in less deprived areas. Information for Scotland is not yet available.
How many healthcare workers have been infected/died?
On 6 April the death of Catherine Sweeney, a care worker from Dumbarton, was announced. Janice Graham was the first NHS worker in Scotland to die from COVID-19.
The Scottish Government does not routinely announce how many healthcare workers have been infected or died from COVID-19. The Telegraph has been publishing information on some of the healthcare workers in the UK who have died during the COVID-19 pandemic.
What is social distancing?
Social distancing is intended to reduce social interaction between people in order to reduce the spread of COVID-19.
People are being told to stay at home and only to go outside for some specific reasons:
- For food, health reasons or work (but only if they can’t work from home).
- To only take one form of exercise a day, for example a run, walk or cycle alone or with members of their household.
- To stay 2 metres (6 feet) away from other people when out.
- To wash their hands as soon as they get home.
The UK Government has published guidance for staying at home and away from others.
What is shielding?
Shielding is a measure to protect extremely vulnerable people from coming into contact with COVID-19, by minimising all interaction between them and others. NHS inform notes that extremely vulnerable people and their households should follow social distancing measures and that those who are extremely vulnerable should not leave their homes and minimise all non-essential contact with other members of their household.
The Scottish Government’s website contains some details on shielding support and contacts.
Who are extremely vulnerable groups?
NHS inform lists groups of people that are extremely vulnerable to COVID-19. It includes people who:
- have had solid organ transplants
- have cancer and are receiving active chemotherapy
- have lung cancer and are either receiving or previously received radical radiotherapy
- have cancers of the blood or bone marrow, such as leukaemia, lymphoma or myeloma who are at any stage of treatment
- are receiving immunotherapy or other continuing antibody treatments for cancer
- are receiving other targeted cancer treatments which can affect the immune system, such as protein kinase inhibitors or PARP inhibitors
- have had bone marrow or stem cell transplants in the last six months, or who are still taking immunosuppression drugs
- have severe chest conditions such as cystic fibrosis or severe asthma and severe COPD
- have rare diseases, including all forms of interstitial lung disease/sarcoidosis, and inborn errors of metabolism (such as SCID and homozygous sickle cell) that significantly increase the risk of infections
- are receiving immunosuppression therapies that significantly increase risk of infection
- are pregnant with significant heart disease (congenital or acquired).
Further information on groups at high risk and at risk groups can be found in a letter from the Chief Medical Officer.
The Scottish Government has also published tailored advice for those who live with specific medical conditions, cancer, diabetes, heart disease, inflammatory bowel disease, chronic liver disease, dermatological conditions, neurological conditions, rheumatic conditions, respiratory conditions and rare diseases.
A UK wide shielding Review Panel has been established to ensure consistency across UK. The main remit of the Review Panel is to review the evidence on potential clinical risk factors for serve illness from COVID-19 and advise the senior clinicians group whether to add or remove specific conditions to the extremely clinically vulnerable group.
Following its first meeting on 22 April, kidney dialysis patients will be included in the shielding list and splenectomy patients have been added to the highest risk group.
Who should have received a letter about shielding?
The letter from the Chief Medical Officer provided information on groups of people at high risk, the identification of these patients and stated that these people who should be sent a letter on how to protect themselves and how to access care and treatment.
The First Minister said on 1 April 2020 “as of yesterday, 94,000 of the letters had been issued, and the others are going out over the next day or so”.
If someone believes that they are in a high-risk group and should have received a letter on shielding they should contact their GP or hospital specialist.
What is the helpline for people at high-risk from COVID-19?
A national helpline has been set up to help provide essential assistance to people who do not have a network of existing support and are at high risk of severe complications from COVID-19. The helpline, 0800 111 4000, will connect people to their local authority who can help them access services, such as medication and emotional support.
How many ventilators does NHS Scotland have?
In a letter to the Health and Sport Committee on 1 April, the Cabinet Secretary for Health and Sport set out the aim that by 5 April the ventilation capacity in Scotland would be just over 560.
On the 7 April, the First Minister said that there are 585 Intensive Care Unit (ICU) beds which either have ventilators or ventilator capacity. The Scottish Government aims to have around 700 ICU beds for COVID-19 patients.
In the Chamber on 1 April the First Minister said:
The Scottish Government has a number of orders in for ventilators with existing ventilator manufacturers, mainly from overseas. Assuming that those orders stay on track, they will be delivered over the next number of weeks or—and I can provide the information in more detail—by the summer. That will take us to slightly more than 1,000 ventilators. That is the first strand, and I stress that those are orders with existing ventilator manufacturers and that they are not dependent on companies repurposing what they do. Secondly, Scotland will seek to participate in the UK-wide procurement. Thirdly, efforts are on-going on a UK basis to see whether companies can repurpose to produce ventilators as well.
What is the Louisa Jordan hospital?
The First Minister has announced a temporary hospital at the Scottish Events Campus (SEC), the NHS Louisa Jordan, in Glasgow to increase patient capacity during the coronavirus COVID-19 pandemic. The hospital will have an initial capacity of 300 beds that could be increased to 1,000 beds. The Louisa Jordan hospital opened on 20 April.
Where can I find advice about what to do if I think I have COVID-19?
A free general advice helpline is available on 0800 028 2816.
NHS Inform advises that people who have developed a new continuous cough and/or a fever/high temperature in the last 7 days should stay at home for 7 days from the start of your symptoms even if you think your symptoms are mild. Do not go to your GP, pharmacy or hospital.
People are advised to phone 111 if:
- their symptoms worsen during home isolation, especially if you’re in a high or extremely high-risk group
- breathlessness develops or worsens, particularly if they’re in a high or extremely high-risk group
- symptoms haven’t improved in 7 days.
If anyone has a medical emergency, they should phone 999 and tell them they have COVID-19 symptoms.
What healthcare is continuing during the pandemic?
The postponement of certain procedures was announced in a Ministerial statement on 17 March. In the statement, the Cabinet Secretary for Health and Sport said she was putting the NHS on an ‘emergency footing’. This included an instruction that boards should scale down non-urgent elective operations from now until further notice. However, she did say:
Vital cancer treatments, emergency, maternity, and urgent care will continue, and patients have our assurance that all appointments will be rescheduled as quickly as possible as we get through the challenge to our NHS that COVID-19 presents. While these are undoubtedly difficult times, we fully expect our NHS to ensure patients are treated in line with their clinical priority, and the impact of COVID-19 on cancer patients has been a priority in all of our planning.
The Cabinet Secretary also outlined that the Scottish Government will establish a national cancer treatment response group to provide ongoing advice and support around cancer.
However, it is likely that there may be some delays in cancer treatment due to efforts to avoid putting people at risk. This is because treatments like chemotherapy weaken the immune system of patients and simply accessing services may increase a person’s likelihood of catching the virus. Those with underlying conditions who get the virus are at a greater risk of serious illness.
According to Cancer Research UK “case by case treatment decisions, based on patient risks and benefits, are still being made across services in Scotland, Northern Ireland and Wales”. They recommend that if patients are concerned then they should speak to their doctor. Guidance on managing cancer treatment has been published in England. On 28 April, the Scottish Government published clinical guidelines for cancer treatment during the COVID-19 pandemic. It is intended that these guidelines will be used in discussion with patients on a case-by-case basis. The patients should be provided with clear information about any changes in their treatment and why this change has taken place.
In relation to emergency treatment, both the UK and Scottish Government have stressed that the NHS is ‘open for business’ and urged people not to delay in seeking treatment.
Is health screening still taking place?
The Scottish Government paused the breast, cervical, bowel abdominal aortic aneurism and diabetic retinopathy screening programmes. This is to enable the re-allocation of healthcare staff to other services and to ensure that people will not miss their screening appointments.
Are immunisation programmes continuing?
The Interim Chief Medical Officer has confirmed that the immunisation programmes should continue during the pandemic. Noting that:
- Routine childhood immunisations should continue as high priority where possible and safe to do so.
- While schools are closed the school programmes have been temporally suspended.
- Immunisations of pregnant and post-natal women should continue.
- Routine shingles programme is suspended (people aged 70 and older can be vaccinated if presenting for another scheduled appointment).
- Pneumococcal vaccination for those in risk groups from two to 64 years of age and those aged 65 years and over should continue. People aged 70 years and older can be vaccinated if presenting for another scheduled appointment.
- The influenza programme 2020-21 will be strategically important in the context of the COVID-19 situation and planning for it should continue as a priority.
What mental health support is available?
The First Minister has announced the roll-out across Scotland of the Distress Brief Intervention (DBI) programme to help people in distress and the launch of a mental health marketing campaign. Which will signpost people to existing advice and direct people to NHS Inform and helplines operated by NHS 24, Breathing Space, SAMH and Samaritans.
Scottish Autism has been given additional funding for its helpline 01259 222 022. As has Spark, which provides relationship counselling, its helpline is 0808 802 2088.
What PPE should NHS and care workers have?
Healthcare Protection Scotland (HPS) note that the four UK countries are adopting the COVID-19 guidance for infection prevention and control in healthcare settings. The guidance on personal protective equipment (PPE) was updated in the 6 April. This guidance seeks to set out recommendations on the use of PPE for health and social care workers in secondary inpatient settings (hospitals), in primary care, outpatient and community settings (such as for GPs), and for ambulance, paramedics, first responders and pharmacists.
The guidance covers how long PPE should be used for and when it should be replaced. It also gives guidance on PPE by healthcare context outlining what are the riskiest procedures for the transmission of COVID-19.
The Cabinet Secretary for Health and Sport wrote to the Health and Sport Committee on the 2 April on the revised PPE guidance, supply and distribution. The Scottish Government made a joint statement on PPE guidance with COSLA and SJC unions on the use of PPE by the social care workforce.
What PPE is available?
There has been much media coverage about shortages of PPE in health and social care settings across Scotland. Responding to this in a Scottish Government news release Protecting our frontline staff the Cabinet Secretary for Health and Sport said:
We have introduced new measures to improve the distribution of PPE, including a single point of contact for all health boards to manage local PPE supply and distribution, and an email address for NHS staff to contact if they do not have what they need. This is covid-19-health-PPE@gov.scot. It will be monitored continuously and allow us to act to resolve any specific supply issues more quickly.
A helpline has also been set up for registered social care providers having problems accessing PPE, with extra staff to prepare orders for social care, additional delivery drivers, longer delivery hours and use of more external delivery companies to increase capacity.
Who needs to wear a facemask?
Different countries have taken varying approaches to their recommendations on whether members of the public should wear facemasks. The World Health Organisation advises that people should only wear a mask if they are ill with COVID-19 symptoms (especially coughing) or looking after someone who may have COVID-19.
Information on the use of facemasks for health and social care workers is included in the guidance Covid-19 personal protective equipment (PPE)
On 28 March, the Scottish Government published guidance on the personal use of face coverings during the COVID-19 pandemic. It notes that the evidence on the use of face coverings is limited, but there may be some benefit in wearing a facial covering when you leave the house and enter enclosed spaces, especially where physical distancing is more difficult and where there is a risk of close contact with multiple people you do not usually meet. It gives a number of examples including traveling on public transport or entering a food shop where it is not always possible to maintain a 2 metre distance from another customer. There is no evidence to suggest there might be a benefit outdoors, unless in an unavoidable crowded situation, where there may be some benefit. The guidance is not mandatory and will not be enforced but will be kept under review.
Are there shortages of medicines and other equipment?
There may be supply disruptions or medicine shortages during the pandemic. The European Medicines Agency (EMA) states that these could be the result of temporary lockdowns of manufacturing sites, travel restrictions impacting exports, export bans, increased demand for medicines used to treat COVID-19 patients and/or stockpiling by hospitals, individuals or by countries.
The EMA has said that some countries are starting to experience shortages, or expecting shortages to occur shortly, of some medicines. These medicines include those used in intensive care such as certain anaesthetics, antibiotics and muscle relaxants and medicines used off-label for COVID-19.
There have also been reported shortages of non-invasive ventilators, oxygen and staff ‘scrubs’.
How are decisions about caring for people with COVID-19 made?
The Scottish Government has published COVID-19 Guidance: Clinical Advice which aims to support NHS staff with decision making during the pandemic. It outlines how people with suspected COVID-19 will be triaged to appropriate care. A Primary Care Hub Triage Guide has also been produced.
The guidance also covers anticipatory care planning for people at higher risk, admission and management in hospital, admission to critical care and treatment including Extracorporeal Membrane Oxygenation (ECMO), non-invasive ventilatory support. It also covers special considerations in paediatrics (child health) and obstetrics (health in pregnancy) and end of life care.
The guidance discusses surge conditions both surge capacity (the ability to manage a sudden influx of patients) and surge capability (the ability to manage patients requiring very specialised medical care) and notes that we when an “extreme surge situation arises” an alternative model of healthcare delivery will be required, which required thoughtful stewardship of available resources.
The Scottish Government has also published Coronavirus (COVID-19): ethical advice and support framework. This notes that in the context of increased demand it may be important to consider fairness of healthcare distribution within the wider population and how finite resources can be most appropriately used and that due to this there may be some complex or challenging decisions where ethical advice or decision-making support will be useful.
The National Institute for Health and Care Excellence (NICE) has published a number of guidelines on COVID-19 including critical care in adults and managing symptoms (including at the end of life) in the community.
On 16 April, the Scottish Government published Clinical Guidance for NHS Scotland: Emergency Department Management of Suspected COVID-19 in Adults which provides targeted clinical advice to support those working in emergency departments within NHS Scotland. The guidance aims to provide a standard for the care provided by emergency departments in the case of suspected or proven COVID-19 infection in adults and to ensure patients spend the minimum appropriate time within the Emergency Department setting.
What support is available for healthcare workers and their families?
The COVID-19 Guidance: Clinical Advice has a section on workforce considerations this notes that “new and existing staff are at high risk of emotional and physical fatigue. Local management teams must ensure the physical and mental wellbeing of all staff, focusing on emotional support, nutrition, hydration and sleep, with clear signposting made available further resources”.
In a letter to the Health and Sport Committee the Minister for Mental Health outlined that in relation to health workforce well-being:
- Boards local arrangements for supporting staff health and wellbeing should be maintained and enhanced. Boards should clearly signpost their workforce to support that can be accessed including through trade unions and professional bodies.
- A designated lead for staff wellbeing should be identified locally. Each Board’s staff governance committee should take on the lead responsibility for positive mental health and wellbeing of the workforce, including practical support (for example on food and accommodation).
On the 24 April, the Cabinet Secretary for Health and Sport wrote to the Health and Sport Committee regarding the COVID-19: Death in Service Benefit for NHS Scotland staff.
What are the different types of tests?
There has been much discussion about the role of testing in managing the pandemic. It is important to note the difference between the tests available.
Firstly, the most commonly used test to date is the ‘PCR’ test. PCR stands for Polymerise Chain Reaction and these tests work by detecting the genetic material of the actual virus. PCR tests are used to determine whether someone is actively infected with the virus and therefore they are useful in guiding whether people should self-isolate and for tracing their contacts to break the chain of transmission.
However, PCR tests cannot tell whether someone has previously had the virus. In order to ascertain previous infection, then people need to be tested for antibodies to that virus. Antibodies are what the body produces to fight an infection, and these remain in the body to deter further infection.
Antibody tests will be useful in guiding social distancing measures and establishing if we have ‘herd immunity’.
What is the Scottish Government’s position on testing?
The Scottish Government is taking a targeted approach to testing. In the first instance, people admitted to hospital with suspected COVID-19 will be tested. Remaining capacity is then being prioritised towards key workers in health and social care and sentinel surveillance. Sentinel surveillance involves testing random samples for evidence of the virus in order to estimate the underlying prevalence in a population.
The Scottish Government also recently announced that people with symptoms who are living with a key worker will also be tested. This is to enable key workers to return to work and not have to needlessly self-isolate if the household member does not have the virus.
On 25 April, the Scottish Government published guidance on testing for key workers in Scotland and guidance on who can access the expanded testing programme in Scotland.
In the test, trace, isolate, support strategy the important role of testing is highlighted. The Scottish Government aims to increase testing capacity to 8,000 samples each day by mid-May. It notes that additional testing capacity, of 4000 tests, is available through the Lighthouse Laboratory arrangements.
It goes on to state that the:
initial estimate is that we may need to provide sufficient tests for around 2% of the population and will therefore need to be able to deliver up to 15,500 tests per day when ‘test, trace, isolate, support’ is fully rolled out.
When will an antibody test be available?
There has been a delay in obtaining an antibody test due to the inaccuracy of those currently available.
The accuracy of diagnostic tests is measured using two metrics; sensitivity and specificity.
Sensitivity is the ability of a test to correctly identify people with a condition (true positives) whereas specificity refers to its ability to accurately identify those without a condition (true negatives).
A good test is one which picks up on a high proportion of true positives and has a low proportion of false positives and false negatives.
The UK Government has procured antibody tests from nine different companies and these are being assessed by researchers at Oxford University. Professor John Bell at Oxford University has stated the tests that have been assessed so far have yielded a high number of false negatives and some false positives.
Using a test with a high proportion of false negatives would mean that people with the virus could unknowingly infect others. False positives on the other hand could lead to people needlessly self-isolating and, in the longer term, putting themselves at risk by thinking they have already had the virus.
On 6 April, Professor Bell was reported as saying that the UK Government is working with suppliers to scale up antibody testing but that this could take at least a month.
Some countries, such as Germany, are pursuing the idea of ‘immunity passports’ by rolling out antibody tests to the population.
Right now we have no evidence that the use of a serologic test can show that an individual is immune or is protected from reinfection. What the use of these tests will do is measure the level of antibodies and it’s a response that the body has a week or two later after they’ve been infected with this virus and these antibody tests will be able to measure that level of seroprevalence, that level of antibodies but that does not mean that somebody with antibodies means that they’re immune.
So we will be issuing some guidance around this because it is a confusing area. There’re a lot of tests right now that have flooded the market and that’s a good thing. It’s a good thing that these things are being developed and that they are available but we need to ensure that they are validated and so that we know what they say that they attempt to measure they are actually measuring.
In the press briefing on 5 May, the interim CMO, Dr Gregor Smith, said that work is underway with various units and the Scottish National Blood Transfusion Service in the area of antibody testing with a hope that information on the prevalence of the infection in the population at any one time will become available and that this would provide a clearer sense of what proportion of the population has been exposed to the virus.
What is the Scottish Government’s test, trace, isolate, support strategy?
On 4 May, the Scottish Government published its test, trace, isolate, support strategy. It is hoped that the implementation of this would interrupt the chains of transmission of COVID-19 in the community by identifying cases, tracing the people who may have become infected by spending time in close contact with them and supporting those close contacts to self-isolate.
The Scottish Government intends to implement the “test, trace, isolate, support” strategy starting with contacts of priority groups that are already being tested, such as patients and NHS and social care workers. In time this would be rolled out so that contact tracing is carried out for all cases identified in the community.
The strategy notes that as people may have very mild or atypical symptoms, or no symptoms at all it will not be possible to identify every possible case by symptom-based assessments. Therefore, it will not be possible to interrupt every possible chain of transmission. Other public health measures such as physical distancing and good hand and respiratory hygiene will remain crucial.
In relation to isolation and support it notes that testing and tracing will only have an impact on reducing transmission in the community if the close contacts of confirmed cases self-isolate.
The strategy states that most people who have been in close contact with a confirmed case will be asked to remain at home for 14 days, isolating themselves as far as possible from other household members. If they then develop symptoms, any close contacts, such as household members, would then be asked to self-isolate. Some people may need to be provided with somewhere to isolate away from the rest of their household.
It also outlines that people may have to self-isolate on more than one occasion.
What is herd immunity?
Herd immunity has been defined as the “proportion of subjects with immunity in a given population”. It is usually used to refer to the level of immunity that is required in a population to stop community transmission and therefore indirectly protect those who are not immune.
Herd immunity can be measured by testing a sample of the population for the presence of the chosen immune parameter, in this case it would be COVID-19 antibodies. People develop immunity when the have already been exposed to an illness either through contracting it or being vaccinated.
At what level would we reach herd immunity?
The level of herd immunity required to prevent further outbreaks, is directly linked to the basic reproduction number of the virus (R0). The higher the reproductive number, the larger the proportion of the population that would need to be immune to achieve herd immunity.
For example, the R0 of measles is estimated to be about 10, which means that each infected person will infect an average of 10 susceptible people. However, once someone has had the infection, then they are no longer susceptible, and it becomes more difficult for a virus to spread.
Because the R0 of measles is so high, about 90% of the population would need to be immune in order to almost eliminate the chance of an unimmunised person coming into contact with an infected person.
For SARS-CoV2, if we go with the estimate that the R0 is between 2 and 3, then around 60% of the population would need to be immune to eliminate the chance of further outbreaks. This relationship is shown in the graph below.
Source: Centre for Evidence Based Medicine (14 April 2020) An introduction to viral reproduction numbers, R0 and Re
An antibody test will allow for an assessment of the level of herd immunity in the population.
What is contact tracing and why is it important?
Contract tracing is used to prevent the spread of infection and to provide a rapid response to those who might be newly infected. It is a fundamental part of outbreak control, used by public health professionals around the world.
Once a patient has tested positive for a virus, work is carried out to identify anyone who has had close contact with them during the time they are considered to have been infectious.
On 2 April, the CMO confirmed that contact tracing is no longer being used as a method to tackle coronavirus as the country had moved form the contain to delay phase of the pandemic. However, as numbers of new cases fall it may be possible to reinstate contact tracing and quarantine measures.
Contact tracing is a significant part of the Scottish Government’s test, trace, isolate, support strategy. This outlines that NHS Boards are leading work to put in place a locally delivered, but nationally supported, service for COVID-19 contact tracing.
Is a contract tracing app going to be used in Scotland?
On 13 April, the First Minister, confirmed that the Scottish Government has been in discussion about the development of a contract tracing app with the UK Government.
The CMO said that the new app looks very promising but would need to be used in combination with traditional methods of contact tracing in the next phase to quickly identify people who have been exposed to the virus to give them advice about self-isolating to stop the virus spreading.
The Scottish Government’s test, trace, isolate, support strategy outlines that digital tools will play a part in contact tracing. The Digital Health and Care Institute are developing a web-based tool for NHS Scotland which will allow people to input details of people that they have been in close contact with and for these to be sent directly and securely to contact tracing teams.
Through NHSX, the UK Government is also developing an app which intends to support contact tracing through proximity tracking. This app will use Bluetooth technology to identify close contacts among other app users and may be useful for identifying people who have been in close physical proximity but who are unknown. This app is currently being trialed by keyworkers on the Isle of Wight.
When will the infection peak?
On 16 April, the Foreign Secretary Dominic Rabb said that cases of COVID-19 in hospital appear to have peaked but it was too soon to ease the restrictions in place to reduce the spread of the virus.
Professor Oliver Linton has undertaken an analysis of the data form the data and forecasts when the peak of cases in the UK. The paper When will the COVID-19 Pandemic Peak? Is being updated weekly. However, Oliver Linton acknowledges that it is a fundamentally challenging task to predict the evolution of the pandemic based on summary statistics as there are well-known issues with the data quality.
Will there be a second peak?
Modelling from the Imperial College COVID-19 Response Team note that, as interventions to mitigate the spread of the virus will lead to only limited herd immunity being acquired in the population, as a consequence, there is the possibility that once the interventions are lifted there is the possibility that there will be a second wave of infection. They go on to say that:
To avoid a rebound in transmission, these [population-wide social distancing combined with home isolation of cases and school and university closure] policies will need to be maintained until large stocks of vaccine are available to immunise the population – which could be 18 months or more [….] The measures used to achieve suppression might also evolve over time. As case numbers fall, it becomes more feasible to adopt intensive testing, contact tracing and quarantine measures
On 16 April, the Foreign Secretary Dominic Rabb Dominic Raab said that “any change to social distancing measures now would risk significant increase in infections”, as well as a second peak and an increase in the number of deaths.
In evidence to the Health and Sport Committee, Professor Hugh Pennington (University of Aberdeen), said:
I do not see any reason why there would be a second peak of this virus and I have not seen any evidence to support the idea. The idea is a hangover from flu pandemic planning, from where the mathematical modellers have injected the notion that we might get a second peak. Rather than a second peak, what we will get if we do not do things properly is the virus dribbling on, with local instances of it taking off. The pattern of this virus has been one of outbreaks, which have been due to particular gatherings of people—on cruise liners, for instance. In South Korea, a religious sect was responsible for a lot of cases, because people met, got infected and took the virus with them to different parts of the country. However, that is not a second peak; a second peak is a flu phenomenon and there has not been one in China for Covid-19. They managed to get the virus numbers down, which took a reasonable length of time.
The World Health Organisation (WHO) is coordinating a group of experts to work towards developing vaccines against COVID-19 and has activated a research and development blueprint to accelerate diagnostics, vaccination and therapeutics for COVID-19.
The European Medicines Agency (EMA) is encouraging developers of vaccines and treatments for COVID-19 to contact them immediately and has regulatory mechanisms in place to speed up the development and approval.
What treatments are being tested in clinical trials?
The EMA is in contact with developers of around 40 potential COVID-19 treatments but, as yet, no medicines have demonstrated efficacy in treating COVID-19.
The EMA lists several potential COVID-19 treatments currently undergoing clinical trials. These include:
- remdesivir (an investigational medicine)
- lopinavir/ritonavir (currently authorised as an anti-HIV medicine)
- chloroquine and hydroxychloroquine (currently authorised at national level as treatments against malaria and certain autoimmune diseases such as rheumatoid arthritis)
- systemic interferons, in particular interferon beta (currently authorised to treat diseases such as multiple sclerosis)
- monoclonal antibodies with activity against components of the immune system.
What vaccines are being tested in clinical trials?
As discussed previously vaccination against COVID-19 could be used to protect individuals and could be used to help establish herd immunity within the wider population. There is work taking place around the world to try to develop a vaccine.
In COVID-19 vaccine development landscape, in Nature, it was reported that, as of 8 April, there were 115 vaccine candidates – 78 which were classed as active and the majority (73) were at an exploratory or preclinical stage. The remaining five were at phase 1 clinical trial. Most of the vaccine candidates are being developed by private companies and most vaccine development activity is taking place in North America.
The EMA notes that it is in discussion with developers on 12 potential COVID-19 vaccines and two vaccines have entered phase 1 clinical trials.
The EMA comments that vaccine development timelines are difficult to predict. Based on past experience it estimates that it might take at least a year before a vaccine against COVID-19 is ready for approval and available in sufficient quantities to enable widespread use. The traditional vaccine development pathway takes 10 years.
On 17 April, the UK Government announced a Vaccine Taskforce and that 21 new research projects would receive funding to progress treatments and vaccines for COVID-19.
On 21 April, Matt Hancock, the UK Government’s Health Secretary, said that Oxford University will be trailing a vaccine on people from 23 April.
Are people immune after they have had the virus and how long does immunity last?
As COVID-19 is a new virus there is still much we do not know about how people develop immunity and it is not yet clear how long immunity will last once someone has been infected.
Professor Martin Hibberd, from London School of Hygiene and Tropical Medicine, argues that once people produce antibodies against a particular coronavirus, they probably have immunity for life. Other commentators have suggested that immunity may last from several months to one year. However, this is another area where more research is needed.
Do we have an exit strategy?
The current social distancing approach is aimed at suppressing transmission and ensuring there is enough capacity within the NHS to provide adequate care to those who need it. However, the measures undertaken to achieve this are unprecedented in their extent and attention has quickly turned to when and how they can be lifted without a further surge in infections.
As mentioned above, a typical response to eradicate a virus would be a vaccination programme. However, as a vaccine is sometime away, it is not a feasible option at the moment.
There have been a number of possible strategies that have been suggested. These include:
- Lockdown until a vaccine and/or treatment is developed.
- Gradually ease off lockdown measures.
- Ease lockdown measures but reintroduce them once infections increase again.
- Immunity passports for those who are found to have antibodies to the virus.
- Case finding through frequent population testing combined with contact tracing and quarantine.
- Use of contact tracing apps combined with frequent testing.
On 16 April, Foreign Secretary Dominic Rabb set out criteria for the exit from lockdown – including a “sustained and consistent fall in deaths” and confidence that the NHS could cope with a second peak.
The initial analysis which informed the approach of the UK and Scotland to the lockdown states:
…intermittent social distancing – triggered by trends in disease surveillance – may allow interventions to be relaxed temporarily in relative short time windows, but measures will need to be reintroduced if or when case numbers rebound.
The World Health Organisation has advised countries to plot a cautious path out of lockdown. Its updated strategy document states that, in the absence of a vaccine, the best outcome we can hope for in the short to medium term is to move from community transmission towards a state of low level or no transmission. In order to achieve this, WHO advises the following six criteria should be met:
- COVID-19 transmission is under control
- Sufficient health systems and public health capacities are in place to detect, test, isolate and treat every case and trace every contact
- Outbreak risks in high vulnerability settings are minimised
- Workplace preventive measures are established
- The risk of imported cases are managed
- Communities are fully engaged and understanding of a move to detecting and isolating all cases and the need to maintain preventive behavioural measures
On the 23 April, The Scottish Government published COVID-19: A framework for decision making. This sets out the approach and principles that will guide decisions around easing the lockdown.
The document contained the following high level messages:
- We must suppress transmission of the virus (R<1.0).
- We must continue to adhere to the advice: stay at home if symptomatic; keep physically distanced; and maintain good hand hygiene and cough hygiene.
- We must develop the public-health capability to deal with cases and outbreaks in a way that prevents widespread community transmission.
- We want to ease restrictions but must be prepared for them to be reimposed as well as lifted.
- Any lifting of restrictions will rely on high levels of support and compliance from the whole population with any continued physical distancing.
- We will be open and transparent about the evidence we have.
- We will consider how our decisions impact on all parts of society.
- Any easing of restrictions will be conducted in a phased and careful manner.
- We will do what is right for the people of Scotland.
- We will adapt as we learn more about this virus.
- We will use surveillance to identify and track the spread of the virus.
- We will develop and deploy the public health services we need to tackle outbreaks.
- We will work with all sectors of society including schools and businesses to develop policies and practices that contain transmission.
- We will rebuild Scotland’s economy, overcoming inequality and advancing human wellbeing.
- We will work with Scotland’s communities to build cohesion and mutual support.
- We will work with and learn from governments around the world as we learn to live with the virus.
The document is also seeking feedback from the public and is intended to aid a national conversation around the future approach to the pandemic.
On 5 May, the Scottish Government published framework for decision making – further information this provides an assessment of current evidence and outlines some options for reviewing some of the lock-down measures that may be able to be adjusted at the end of the next review date which is the 28 May. The options discussed are:
- Changes to advice about staying at home.
- Changes to advice about visiting other households.
- Options for resuming care and support for those most affected by the current restrictions.
- Changes affecting businesses that have been subject to restrictions or closure.
- Options for allowing pupils to return to school.
Will Scotland follow the same exit strategy as the rest of the UK?
To date, Scotland has been following, in general, the same interventions to reduce the infection rate as the rest of the UK. The Scottish Government did place a ban on large gatherings before the rest of the UK.
It is possible that in the future that Scotland or parts of Scotland could make different decisions about what interventions are needed to control the virus. On 13 April, the First Minister said that “simplicity of messaging” might make it easier to maintain a “consistent” approach across the whole UK, but said if the evidence showed different timescales or approaches should be used in Scotland then “we will not hesitate to do that”.
The framework for decision making which was published by the Scottish Government, states:
While we will continue to operate within a four nation UK framework and align our decisions as far as possible, we will take distinctive decisions for Scotland if the evidence tells us that is necessary.
Lizzy Burgess and Kathleen Robson, Senior Researchers.