Transparency data

SAGE 36 minutes: Coronavirus (COVID-19) response, 14 May 2020

Published 12 June 2020

Thirty-sixth SAGE meeting on COVID-19, 14 May 2020.

Held via Video Teleconference.

Summary

1. SAGE advised that social bubbles have the potential to create significant unwanted effects and advised against their introduction in the short term, when other distancing measures have only just been lifted, or in conjunction with release of other measures.

2. SAGE advised that further release of distancing measures should not be contemplated until effective outbreak surveillance and test and trace systems are up and running.

Situation update

3. The steady decline in hospital and care home deaths continues; the rate of decrease is slowing, but not more than would be expected.

4. There is a continued downward trend in hospital admissions, with some regional variation.

5. CO-CIN data show a decline in absolute numbers of hospital acquired infections (but they are increasing as a proportion of total).

6. Latest ONS data show overall prevalence is driven in part by healthcare workers. There are roughly 12,000 new cases per day and currently around 150,000 infected overall in England. Prevalence was slightly higher than in the last set of results but the difference is expected due to small numbers of cases.

7. Estimate of R remains between 0.7 and 1. SPI-M will advise on lead indicators for detecting changes in numbers of infections or R at SAGE on 19 May.

8. Data show increased seropositivity over time in London, with an adjusted seroprevalence of 13% to 17.4% (medium confidence). Seropositivity is higher in London than in other parts of the country (high confidence). Data for child seropositivity suggest it is roughly equivalent to that for adults. Data for infections from ONS also show a broadly similar infection rate for adults and children.

9. SAGE agreed the importance of serological and other testing data that is being collected in many hospitals locally, including from longitudinal studies of healthcare workers, being collected in one place. This will help determine whether seropositivity is associated with reduced infection and reduced carriage.

10. SAGE endorsed the Environmental and Modelling Group paper on principles of risk assessment.

11. Further research on environmental questions should be organised via a consortium, given the multidisciplinary requirements.

Actions:

• Environmental and Monitoring Group and NERVTAG to advise UKRI on potential consortium members for research funding on a) environmental spread and b) infectiousness (and relation to PCR positivity)
• SAGE secretariat to circulate the SAGE-endorsed Environmental and Monitoring Group paper ‘Using understanding of transmission routes to inform risk assessment and mitigation strategies’ to key departments, with clear instructions to act on relevant recommendations; Cath Noakes to make one alteration to paper in relation to faecal transmission (by 15 May)
• NHS Medical Director to ensure regional aspects of the ONS survey are fed into NHS planning and to liaise with Ian Diamond over future requirements (by 19 May)
• Health Data Research UK (Andrew Morris) to identify an approach to aggregate serological data from studies and surveys (including NIHR and other longitudinal studies); NHS Medical Director to capture any relevant serological data from NHS Trusts for this data repository (by 19 May)

Social bubbling

12. SAGE advised strong caution concerning the introduction of social bubbling — particularly in the short term, when other distancing measures have only just been lifted, or in conjunction with release of other measures. SAGE has advised previously against making too many changes at once.

13. While SAGE noted the impact of lockdown on wellbeing and theoretical benefits of bubbling for some people (for example those experiencing loneliness, stress, economic hardship), it cannot be regarded as a universal good; for some people bubbling is impossible, too complicated or there may be no other household for them to link to.

14. Any bubbling will increase infection risk. If introduced, bubbling should only happen when it is safe to do so from an epidemiological perspective and on a very modest basis initially.

15. Currently, incidence is too high and R close to 1. Active contract tracing should be a pre-condition of introducing bubbling.

16. Modelling of risk to date has assumed schools remain closed and that R is 0.8 or lower. Risk would be amplified if schools are open and if workplaces are busier.

17. For bubbling itself, risk can be minimised if participating households are small, for example two one-person households interacting (1+1) or (slightly more risky) a one-person household interacting with a larger household (1+n). Bubbles of larger households with multiple individual connections provide a significant potential risk.

18. Consideration is needed, however, of bubbling involving multi-generational families including older people, of families which include vulnerable individuals or which include a healthcare worker.

19. SAGE also noted significant challenges to operationalising bubbling and setting out unambiguous guidelines. Isolation on contact with an index case would have to involve the whole bubble.

20. Messaging needs to be clear prior to launch to prevent or reduce non-adherence.

21. SAGE advised that non-adherence with guidelines could lead to spread of the infection, and that non-adherence was likely, especially if larger households are bubbled together.

22. SAGE noted a paucity of evidence from the adoption of bubbling in other countries — but that there is already some evidence of potentially significant non-adherence with bubbling guidelines.

23. Other unintended consequences are possible.

24. SAGE concluded that bubbling may be appropriate in limited circumstances — and that policy development in the area would benefit from being able to quantify and compare its impacts with other measures, though quantification is challenging and data sparse.

25. DHSC polling could in future ask about interactions among households to determine whether bubbling is already happening.

Actions:

• SAGE secretariat to provide a covering summary note on social bubbling, setting out SAGE’s advice and caveats (by 15 May)

Surveillance

26. SAGE noted the challenges facing the Joint Biosecurity Centre (JBC), including how to identify local outbreaks, the required pace of testing, what NPIs could be implemented in response (and how quickly), public messaging, the potential for outbreaks undefinable by local geography (for example more likely linked to workplaces than schools) and variation in regional capacity.

27. SAGE noted the importance for the JBC of clearly defining its overall objective — plus the value of user-centred design, lead indicators as well as lag indicators, connected multi-dimensional data, privacy issues and public buy-in (including economic incentives or disincentives to identify outbreaks); early identification of any outbreaks should be a cause for public celebration and recognition.

28. SAGE advised that further release of distancing measures should not be contemplated until effective monitoring and test and trace systems are up and running.

29. SAGE offered ongoing rapid support and advice to JBC.

Actions:

• SAGE secretariat to capture key science questions and advice around the design of monitoring and relevant measures for the Joint Biosecurity Centre (by 15 May); Evaluation Sub-group, with input from SAGE volunteers, to refine these questions as basis for further modelling and behavioural commissions (including modelling of reactive closures at the level of an individual workplace) and provide advice to JBC by 15 May
• NHS Medical Director to ensure input from NHS is fed into design of Joint Biosecurity Centre (by 15 May)

Asymptomatic cases and infection

30. NERVTAG has reviewed various studies on asymptomatic infection. Many do not differentiate between asymptomatic or pauci-symptomatic individuals and pre-symptomatic individuals.

31. SAGE noted that longitudinal sampling in the ONS study will assist in clarifying this difference going forward but needs to include more than “asymptomatic on the day of infection”.

32. Taking all evidence into account, between 10% and 35% of individuals may be truly asymptomatic (low confidence), and many more may have few symptoms. Review of ONS data will help refine the estimate.

33. It is possible that asymptomatic individuals are less infectious, but this cannot currently be quantified. There is a key knowledge gap concerning how positive testing correlates with the presence of live, recoverable virus (for example infectiousness), although PHE is currently investigating this.

Actions:

• PHE (Maria Zambon) to provide current summary of COVID-19 biology for consideration by NERVTAG (by 15 May) to inform its input to planned consortium researching infectiousness

Virus variants

34. SAGE noted that it is currently hard to interpret the biological consequences of sequence variations in the virus — but acknowledged the ramifications of mutation and virus recombination in areas such as diagnostics and vaccines.

35. SAGE agreed that the biology of the virus should be the focus of an open research call.

Actions:

• Wendy Barclay and Peter Horby to liaise with Wellcome (Jeremy Farrar) to develop with UKRI an open research call to better understand biology of COVID-19 variants

List of actions

• Environmental and Monitoring Group and NERVTAG to advise UKRI on potential consortium members for research funding on a) environmental spread and b) infectiousness (and relation to PCR positivity)
• SAGE secretariat to circulate the SAGE-endorsed Environmental and Monitoring Group paper ‘Using understanding of transmission routes to inform risk assessment and mitigation strategies’ to key departments, with clear instructions to act on relevant recommendations; Cath Noakes to make one alteration to paper in relation to faecal transmission (by 15 May)
• NHS Medical Director to ensure regional aspects of the ONS survey are fed into NHS planning and to liaise with Ian Diamond over future requirements (by 19 May)
• Health Data Research UK (Andrew Morris) to identify an approach to aggregate serological data from studies and surveys (including NIHR and other longitudinal studies);
• NHS Medical Director to capture any relevant serological data from NHS Trusts for this data repository (by 19 May)
• SAGE secretariat to provide a covering summary note on social bubbling, setting out SAGE’s advice and caveats (by 15 May)
• SAGE secretariat to capture key science questions and advice around the design of monitoring and relevant measures for the Joint Biosecurity Centre (by 15 May); Evaluation Sub-group, with input from SAGE volunteers, to refine these questions as basis for further modelling and behavioural commissions (including modelling of reactive closures at the level of an individual workplace) and provide advice to JBC by 15 May
• NHS Medical Director to ensure input from NHS is fed into design of Joint Biosecurity Centre (by 15 May)
• PHE (Maria Zambon) to provide current summary of COVID-19 biology for consideration by NERVTAG (by 15 May) to inform its input to planned consortium researching infectiousness
• Wendy Barclay and Peter Horby to liaise with Wellcome (Jeremy Farrar) to develop with UKRI an open research call to better understand biology of COVID-19

Attendees

Scientific experts

• Patrick Vallance (GCSA)
• Chris Whitty (CMO)
• Andrew Curran (CSA HSE)
• Andrew Morris (Scottish COVID-19 Advisory Group)
• Andrew Rambaut (Edinburgh)
• Angela McLean (CSA MOD)
• Calum Semple (Liverpool)
• Cath Noakes (Leeds)
• Charlotte Watts (CSA DfID)
• Fliss Bennee (Wales Technical Advisory Cell)
• Graham Medley (LSHTM)
• Ian Boyd (St Andrews)
• Ian Diamond (ONS)
• James Rubin (KCL)
• Jenny Harries (dCMO)
• Jeremy Farrar (Wellcome)
• John Aston (CSA HO)
• John Edmunds (LSHTM)
• Jonathan Van Tam (dCMO)
• Lucy Yardley (Bristol)
• Maria Zambon (PHE)
• Mark Walport (UKRI)
• Michael Parker (Oxford)
• Nicola Steedman (dCMO Scotland)
• Peter Horby (Oxford)
• Rob Orford (Health CSA Wales)
• Robin Grimes (CSA MOD)
• Sharon Peacock (PHE)
• Stephen Powis (NHS)
• Venki Ramakrishnan (Royal Society)
• Wendy Barclay (Imperial)
• Yvonne Doyle (PHE)

Observers and government officials

• Ben Warner (No.10)
• Vanessa MacDougall (HMT)

SAGE secretariat

• Simon Whitfield
• Stuart Wainwright

Total participants: 51

4 observers and government officials and 11 Secretariat members redacted.