COVID-19 Committee

Meeting date: Thursday, February 25, 2021

Official Report 695KB pdf

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Next Steps

Good morning, and welcome to the COVID-19 Committee’s seventh meeting in 2021. We have received apologies from Monica Lennon MSP, and David Stewart MSP is joining us as a substitute; I welcome him to the meeting.

This morning, the committee will take evidence from three witnesses on Covid-19: next steps. I welcome Professor Michael Baker MNZM, who is professor of epidemiology at the University of Otago, Wellington; Professor Siân Griffiths OBE, who is emeritus professor at the Chinese University of Hong Kong; and Professor Mark Woolhouse, who is chair of infectious disease epidemiology at the University of Edinburgh.

I am advised that Professor Baker will be slightly late to the meeting, for technical reasons, but in any event we will commence. We have a lot to cover this morning, so we move straight to questions. I note that Professor Griffiths needs to leave the meeting by 10 am.

Members will have eight minutes each to ask questions of witnesses so, as ever, I ask that we keep our questions and answers as concise as possible. If there is time for supplementary questions, I will indicate that, once all members have had a chance to ask their questions. If members can say to whom they are directing their questions, it will assist the broadcasting team. I ask witnesses to wait a moment for their microphone to be switched on before speaking.

I will ask the first question. What are your views on the various strategies that are available to deal with Covid-19? Which strategy is best for Scotland, and how does it fit in with wider international comparators? I ask Professor Woolhouse to start.

Thank you, convener—that is a very broad question to start with. The current situation is that the epidemic appears to be in decline in Scotland. The numbers of cases, hospitalisations and deaths are coming down. The vaccine roll-out is going extremely well; the numbers of those who have been vaccinated have exceeded most people’s expectations of a few weeks ago.

There are two other important points to make about the vaccination programme. The first point is that the coverage is very good. The take-up of the vaccine has been very high—in the most vulnerable groups that have been vaccinated to date, the take-up rate as a percentage is well into the high 90s. A few weeks ago, when the vaccination roll-out programme started, there was concern that take-up might be a lot lower, so that is very good news indeed.

Turning to the second point, the other good news that has come through in the past few weeks concerns the performance of the vaccine. Only this week, my colleagues at the University of Edinburgh published a paper on the efficacy of the Pfizer and AstraZeneca vaccines in Scotland. The numbers are still small, but it looks as if the vaccines provide about 80 per cent protection in terms of keeping people out of hospital, which is very good news. All the indicators are very positive.

As we all know, the Scottish Government has a policy of cautious relaxation, which is driven by data. My interpretation of that position is that the data are looking very good, so I hope that it will be possible to relax somewhat ahead of the schedule that we might have had in mind a few weeks ago. The signs are very positive.

Your question implies consideration of where we are going to end up from here. I will give two brief comments on that. First, the common goal—there has been a lot of discussion on this in the epidemiology community in the United Kingdom—is that by September, we would like to be in a position in which we are very confident that winter 2021-22 will be a lot better than the winter that we are going through now. There is a lot of work to be done between now and September to ensure that that is the case.

Secondly, we are fairly clear—as the chief medical officer for England and many other commentators have said—that, during winter next year, we will be living with some level of Covid-19. We cannot yet say with certainty how good or bad the situation will be, but there will be Covid-19 in the UK next winter. I will stop there, but I can go on in more detail if you wish.

Thank you for that. I ask the same question of our other witnesses, starting with Professor Griffiths.

I thank the committee for inviting me to the meeting. I concur with everything that Professor Woolhouse said. Progress across the UK, and in Scotland in particular, has been especially good in terms of vaccine uptake. In addition, we have learned some lessons, such as the need to focus on care homes.

Nonetheless, I will raise a few additional points. First, we need a global approach. Yesterday, the first vaccines were sent to Ghana as part of the COVAX programme, which is really important. We could have less Covid in our country, but if Covid remains in other parts of the world, we will not prevent the spread of, or eliminate, the disease. We have to have a global perspective.

Secondly, we need to continue to look at inequalities. Around the world, and across the UK, we have seen that areas of poverty and deprivation, and areas with certain groups, such as ethnic minority groups, have experienced higher rates of infection and hospital admissions. The figures for Scotland that Professor Woolhouse quoted are reassuring, in the sense that the inequalities gap does not appear to be so large in Scotland, but that does not mean that we can relax. If we are going to try—[Inaudible]—we need to continue to think about the structural inequalities, and a whole set of issues such as ways of working, occupations, housing and diet. We need to remember that Covid is not just a disease—it is part of a broader social approach that we need to adopt for the future.

Finally, if we are going to contain Covid in the winter, we need an excellent test and trace programme in every country, and in the UK and Scotland in particular. We need to be able to identify cases; do the genomic sequencing, which we in the UK are particularly good at, through the COVID-19 Genomics UK Consortium; and ensure that, as soon as cases start to emerge, there is isolation, contact tracing, quarantine and an understanding of where the disease might have spread so that we can stop the chain of transmission. In that way, we will be able to co-exist with Covid, which the chief medical officer for England, and the other chief medical officers, think is the most likely situation.

I welcome Professor Baker to the meeting, and ask him the same question.

Greetings. Could you repeat the question, please?

Of course. I am sorry—I should have done that. My question was very broad. It was about the various strategies that are used internationally to approach Covid-19, and which strategy you feel is most appropriate for Scotland.

Obviously, I am presenting a perspective from the other side of the world, and New Zealand has pursued an elimination approach from very early on in the pandemic. I understand, from talking with colleagues in Scotland, that you were very close to achieving the same goal at certain points.

The essence of that approach is to aim to have no Covid transmission in the community, and New Zealand has used three broad approaches to achieve that. The first involves managing borders, with very tight quarantine and testing. We then use measures to decrease transmission at a population level through physical distancing, the use of lockdowns in a short, decisive way and, more recently, mask use.

The third major strategy has been testing and tracing. We initially used quite an intense lockdown for five weeks, followed by a less intense lockdown for couple of weeks, and we emerged into a virus-free country. That gave us time to build up our testing and contact tracing system. We now get occasional incursions of the virus, mainly through border failures, and we can manage those quite effectively with testing and contact tracing. Another major strategy is to have in place a social safety net to support the most vulnerable groups, who are affected mainly as a result of the intervention itself.

The core essence of our approach is the unifying goal of having no transmission in the community. We are now starting to roll out vaccines. We are a bit behind the UK on that, but vaccines are now being used selectively for border workers to improve border biosecurity.

I see that Professor Woolhouse wants to come in. Do you have any observations on that approach and how it applies to Scotland in particular?

Yes, I do. I just want to correct one slight misinterpretation in what was said. Scotland was not close to elimination at any stage during the epidemic. We had low numbers of reported cases during the summer but, at the same time, the modelling groups were estimating the number of cases that were present, using a method that has been very well validated since—it works, so the estimates are reliable—and those estimates showed that we never fell below 500 cases in Scotland. There is some uncertainty around that, but that is the best estimate.

More difficult still, the majority of those cases—perhaps 90 per cent of them—were not reported. The reason is that, at that stage, the virus was circulating in particular in groups of young adults, who do not show many symptoms. As soon as the testing capacity increased in August, there was a dramatic increase in the number of cases that we were detecting in those groups, and we proceeded.

I agree with Professor Griffiths on the genome sequencing work. COG-UK is a world-leading facility, and it will be valuable for Scotland as we move forward. That work showed quite clearly that the lineages that were present in the first wave in Scotland were still present in the second wave. The sequencing was not examining that many cases at the time, so they were not always found, but they were present, so we were not close to elimination in Scotland.

Is elimination a realistic strategy for Scotland?

In the short term, it is not. We are still trying to manage the current wave. In the medium term, it will depend very much on the performance of the vaccines that we have now, and in particular on whether they are able to reduce the reproduction number by stopping the spread of infection. They do that in two ways: they either stop people getting infected in the first place or, if people get infected, the vaccines reduce the rate at which those people pass infection on, usually because they will have a lighter viral load in the upper respiratory tract.

It may be that the vaccines are very good at stopping transmission, in which case we have the prospect of reaching the herd immunity threshold. However, that would be difficult—the current estimates show that we would have to immunise at least 75 and perhaps 80 per cent of the population in order to do that. If we manage to do it, and if we continue to maintain a very high level of herd immunity, the virus will not be able to circulate freely. That does not mean that there will not be outbreaks—if the virus is introduced through any route, it will be able to transmit in the unprotected fraction of the population—but, if we can reach the herd immunity threshold, those outbreaks should not develop into a full-blown epidemic.

Right now, we do not know whether that can be done. As I said, there are some grounds for optimism, but we cannot be fully confident that the herd immunity threshold is reachable. If it is not, we will have to reach some sort of position in which we are living with a balance between the rate at which the virus is spreading in the community and the rate at which we are vaccinating people. We would hope that there would be a low level of continued infection but, without reaching the herd immunity threshold, elimination would not be practical.

I thank you all for those answers. We come to questions from my committee colleagues, starting with David Stewart.

I will build on the convener’s questions—I will start with Professor Baker, and then I would welcome contributions from the other witnesses.

Professor Baker, in your webinar for the Usher institute, you said that elimination seems to be more effective than suppression or mitigation. Can you explain and expand on that point?

09:15  

It depends on the criteria that we use to judge effectiveness. In New Zealand, we have had very low case numbers and very low mortality, and our economy has performed well and is recovering well, because there is a high degree of certainty that elimination has been achieved. As with other countries that have pursued elimination successfully, the health outcomes are much better, as are the economic outcomes.

In New Zealand, we have spent very little time under lockdown—in fact, our time in lockdown is among the shortest of the countries in the Organisation for Economic Co-operation and Development. That is simply because, by having short, sharp lockdowns, we have eliminated the virus and focused on keeping it out at the borders, and that strategy has been very beneficial. Based on those criteria, it has been more effective than pursuing suppression.

Would the other witnesses care to comment on my question?

I checked with my colleague Professor Gabriel Leung on the situation in Hong Kong, which would say that it is following a zero Covid strategy. It is building on the experience of severe acute respiratory syndrome—SARS—but it is also having to do frequent lockdowns in small areas.

Hong Kong does what it calls “ambush-style lockdowns”. It is geographically very different from Scotland, and it has a very different, and homogeneous, population. At present, it has 40 cases, and it knows that 25 of those cases involve the British strain. It knows a huge amount of information about the cases, but the disease keeps coming in—for example, through the Filipino helpers, who bring in the disease from the Philippines.

Across the border in China, there are rigorous controls in place. Everybody has to go into hotel quarantine if they go into the country; I think that the same applies in New Zealand. The quarantine time is two weeks, plus one week—so, three weeks—if you are not a Hong Konger. Those criteria are very rigid and strict, and if you are going to drive through that policy, you have to accept that. We do not have such a policy in place here, and the question is whether we need it in place, in particular now, as we are starting to lift lockdown.

Professor Woolhouse, do you have any comments?

Yes, I do. I thank Michael Baker for his description of what has happened in New Zealand. The thing to remember is how New Zealand got into that position in the first place. Professor Baker will correct me if I am wrong, but I have checked this, and I think that I am right. New Zealand implemented in mid-March the type of strict border controls that Professor Griffiths just described, and it went into full lockdown on 25 March to try to eliminate the few cases that had got into the country at that time. As a result of those actions, New Zealand has arrived at its current position; I think that we would all agree that it is now one of the best places in the world in terms of managing its local epidemic. It did that through actions that took place during the first stage in March.

If the UK had put border controls in place in mid-March, as the UK Government Home Secretary has suggested in the past, it would have been far too late. The UK’s epidemic was seeded in mid-February, around half term, by large numbers of cases—thousands of cases—that were brought in from France, Italy and Spain. Even if we had put border closure measures in place when New Zealand did, it would have had very little effect—it would have been much too late.

The date on which New Zealand went into lockdown was 25 March, which was after the UK went into lockdown on 23 March. New Zealand is very fortunate—I am very happy that this is the case—as its epidemic was seeded way behind the UK’s epidemic, so it was able to take actions at the time that it did and still achieve the effect that we have seen. That is the main reason why New Zealand is different: the early history of the epidemic.

With regard to achieving elimination in Scotland, the UK or any other country, it is worth looking at who else has done that. This is a very easy comparison: let us compare the first and second waves, because those waves have been pretty universal around the world in countries that have Covid. No country with an epidemic the size of Scotland’s epidemic has managed to have a second wave that was smaller than the first wave; they all had bigger second waves. No country with an epidemic half the size of Scotland’s has avoided a bigger second wave, and nor has any country with an epidemic one tenth the size of Scotland’s. There appears to be no route—or at least no route that any country in the world has found—to get from where Scotland is now to where New Zealand is now. The route was open back in February. We missed our chance to be like New Zealand back in February. By March, when New Zealand took the route that it did, it was already too late for us, and now it is far too late.

The possible game changer, as I mentioned in my previous answer, is the vaccines, and whether we can achieve the herd immunity threshold, but that is a different ballpark entirely. There is no way now that Scotland can get to where New Zealand is now.

Thank you—those answers were fascinating.

My final question is this: would it be fair to describe the strategy in the UK and Scotland as one of suppression? I will throw three different statistics at you; I understand that they could be spurious and unconnected. Yesterday’s edition of The Times quoted a University of Oxford study, which said that the UK has

“one of the strictest lockdowns in the world”.

In fact, it is the third strictest in the world—for completeness, I note that we were beaten by Venezuela and Lebanon. Secondly, we have the second highest vaccination rate in the world—as you will know, Israel has the highest rate. I think that we are at around 26 per cent; that is the last figure that I have. Finally, the last figure that I looked at—I accept that it could be out of date, or there could be a lag—showed that the death rate for Covid-19 in the UK was the highest per million in the world.

I appreciate that I can throw three statistics together and they may not be connected, but I wonder whether the witnesses can draw anything from them with regard to the suppression strategy in Scotland and the UK. Where do we go from here?

I was very interested to hear Mark Woolhouse’s comments. One country has provided a model for a return from quite an intense pandemic wave, and that is Australia. It had a border breach that resulted in several thousand cases and 800 deaths in the state of Victoria. For a period, the rate there was higher than the rate in the UK; the state had a prolonged lockdown of around eight weeks, and then emerged into a virus-free country. That response was driven by modelling, which showed that it would work, and it was followed by a decline in rates.

I do not know the extent to which researchers in Scotland have looked at the experience of Victoria in Australia, but it is encouraging to see that it is possible to return from very high rates of disease. In Victoria, it was thought that the situation might be unrecoverable, but the approach succeeded. I would be interested to hear from your researchers in Scotland about whether they have looked at the Victorian experience.

Professor Griffiths, do you have anything to add?

I was just looking to see whether there was a link between the statistics that you quoted. As you said, however, they are simply three statistics. One thing that I learned when we did the inquiry into SARS in Hong Kong was that you need to take a point, look back—objectively, without attaching any moral blame—and then look forward.

It is very easy, with something such as the highest death rate, to start to criticise before you have taken a calm look and asked, “Why did this occur? Is this a real statistic? Are we comparing like with like across different countries?” and so on. We have to place those statistics in context. Having the second highest vaccination rate is something for us to celebrate, because we know that we have a fantastic vaccination programme in this country—all parts of the UK are overachieving on the vaccination rate. That is a very good statistic. As Professor Woolhouse said earlier, we need to look at the impact over time. As we get higher levels of vaccination, and we move further towards herd immunity, it will allow us to do different things. It is hoped that the death rate per million will start to go down, so that, if we took a cut in three months’ time, it would show that we would not have the highest rate.

On the question of countries with the strictest lockdowns, we have a pretty strict lockdown here, but I doubt that it is as strict as the lockdown in Wuhan, which was pretty strict. We do not have so much mandating in our lockdowns—a lot of it relies on voluntary compliance, which is actually a good thing when it comes to releasing people from lockdown. I am not sure that the statistics that you quoted create a picture, but they give us insights at a certain point. We might have an inquiry, at some point in time, that does not attach blame but looks at what we do next time. For example, Hong Kong brought in travel restrictions in January, as soon as it saw that there was a SARS-like epidemic, because it had learned from the SARS epidemic in 2003. When we look forward, we will have learned many things—for example, on care homes—from countries around the world, on which we would need to take different strategies. Individual statistics give us pointers to things that we need to look to for the future.

We have had several lockdowns, including two full lockdowns, in Scotland, but they have not managed to achieve elimination. The difference with the experience in Victoria is that we were starting from a higher base. Our modelling would suggest that in order to get from where we are now to elimination, via the mechanism of lockdown—leaving the vaccines out of it for the moment—we would have to stay in a very strict lockdown for very many months. You cannot have an elimination strategy—in Australia, Scotland or anywhere else—and also relax measures. Those are contradictory aims. If you were to go for elimination, you would have to be in lockdown for a very, very long time, given where we are starting from. The fact is that we were not ever starting from the same position as Australia or New Zealand.

With regard to the death rate, I agree with Professor Griffiths—we will have to reflect on that carefully. I am very concerned—I have said this many times—that the death rate in the UK is high because we have concentrated so much on lockdown and other ways of trying to suppress the virus. We have taken the approach that the main way of protecting the people who are vulnerable to the virus is to try to suppress transmission in the whole community. I and colleagues at Health Protection Scotland looked into an analysis of the death rate in the first wave. We counted up the number of deaths that occurred—I have to be very clear on this—because of infections that were acquired after the 23 March lockdown was in place. That included people who got infected after the lockdown started. Our best estimate was that between half and 75 per cent—three quarters—of all the people who died during the first lockdown got infected after lockdown began. You might remember that there was a long tail to the epidemic, so there were infections happening there—there were many, many of them. The majority of people who died did so because of infection that they got in that tail.

What that tells me is that we did not pay nearly enough attention to doing things beyond lockdown, such as protecting the vulnerable in care homes and in the wider community. We simply did not do that enough. All that we had was shielding, which—according to most people—was not a particularly effective policy, and a little bit of extra advice for the over-70s. We could have put so much more effort into protecting the people who needed it. We now recognise that we did not do enough to protect those in care homes. To come back to the point that Professor Griffiths made about the need for reflection, we need to recognise that the same is true for the vulnerable people in the community—we did not do enough to protect them either. Lockdown did not save the majority of those people, and we will have to reflect on that very hard.

That is helpful. I thank all the witnesses for their answers to my questions.

09:30  

What is your judgment on how easy it will be to suppress the virus as we move forward, given that we are seeing genetic mutation? At present, it seems that the vaccination programme itself is exerting a selection pressure on the virus. I know that a bit of crystal-ball gazing is required, but what is your judgment with regard to how quickly the mutations can arise and what their impact will be? Perhaps Professor Baker can start.

That is a very good question. Inevitably, the more infectious variants of the virus will have a selective advantage and so will become dominant. That is just the nature of the biology and the natural selection that occurs. That will favour more infectious variants, but it may also favour those that can evade the immunity from vaccines. The extent to which that will occur is not known.

We felt that it was very important to have continuing public health measures in combination with vaccines, and to clarify the ultimate goal. To reduce the selective pressure, we want to have minimal circulating virus, and that—again—is an argument for elimination. Even if it requires a sustained effort, there are huge additional benefits, over and above saving lives in the short term, in reducing opportunities for viral evolution.

I am not really an expert on viruses and viral transmission. We saw the Kent virus taking off in December, and we know from yesterday’s briefing that 85 per cent of cases in Scotland involve the new variant. The Kent variant took off at the time when we were reducing lockdown and moving towards Christmas, and the most recent peak occurred because the virus took hold. We have had a demonstration, therefore, of what happens when a new variant comes along and takes off.

The ease of suppression will depend on how flexible the vaccines are and whether they can be tweaked to cover all the variants as they emerge. Oxford is taking the approach that that can be done; the teams are currently working on how to ensure that the vaccines are alert to the current strains. We need to keep in place high levels of vaccination and low levels of virus in the community, and we need to understand the nature of the virus that is circulating. Mark Woolhouse and I both mentioned COG-UK, the genetic sequencing facility in the UK, which is shared across the countries of the UK and more globally. It is a world-leading facility, as Anthony Fauci from the United States said yesterday.

We can see that we need to keep the vaccination programme going; keep the social distancing measures in place as long as we need to in order to suppress the virus and keep the R rate down; and continually monitor the situation. We need a dynamic policy that understands what variants we have. That raises the issue of needing a global approach. There is no point in our understanding the virus really well if we have people travelling into the country, or if we travel. There is a whole question around travel and opening up borders and the global economy. All those different things need to be thought about as we move forward, in the context of the need to suppress transmission of the virus.

Professor Woolhouse, do you want to add to that?

Yes—there were a couple of points in your question. You asked whether the new variant can be suppressed in Scotland. The epidemiological situation in Scotland right now is quite delicate and complex. The reduction in cases that we have all seen over the past few weeks is mostly a reduction in the old variants. The new variant has declined slightly, but it has more or less held steady.

When I was first alerted to the new Kent variant back in December, I was very concerned that it was going to be extremely difficult to suppress it through lockdown. We said at the time that we were on a knife edge in respect of whether we could do it or not, and that is exactly what we are now seeing in the data: we are on a knife edge in suppressing the new variant. To go back to an earlier part of the discussion, that has implications for the elimination of the newer variants through suppression methods such as lockdown. I am not clear on how we could achieve that—we are barely driving down the new variant at all. At the beginning of the second wave, the new variant was relatively rare in Scotland, but it is now by far the dominant variant, and it will soon take over.

That brings me to another point. The Scottish Government’s very nice background document, which supports the recent statement on the road map, contains a picture that shows the sequence of variants over time across the UK. What we see is one variant after another—one wave of different variants after another. That is what you always see when you look at these kinds of genome data on an endemic virus or a prolonged epidemic: waves of different variants coming on. We will have to deal with that for the foreseeable future. I absolutely agree with the comments from Professor Griffiths that we need sustainable ways to deal with the new variants. Adjustments to the vaccines would seem to be the primary way that we have of dealing with that.

I will make one comment about what drives the evolution of new variants. It is actually quite complicated. It should go without saying that, if we have more cases, there are more opportunities for evolution to happen, but that is not quite how it works. Let us look at the evolution of the new Kent variant. Our best understanding of that variant is that it arose in a single patient who was infected with coronavirus, was immunocompromised and was being treated with an antibody therapy. It was a very special case, and a large number of mutations were able to happen in that one patient.

That is not a typical case—it is a particular combination of circumstances, which we can learn about and understand. The more we understand about where the evolution of these new variants happens, the more we can take much more targeted measures. We can highlight procedures or patients that we have to be careful about. For example, monitoring vaccine failures is an obvious way to see whether there are particular circumstances in which those variants are arising.

A final point of interest on the evolution of the new Kent variant is that it happened in September, but we did not even see it as a problem until December, several months later. Variants arise at low levels and they circulate. There are literally hundreds—globally, there are thousands—arising all the time; they have to be sifted, and it must be decided which ones are of concern. At present, Public Health England is watching a dozen or so variants of concern, and the Americans were reporting a new variant in California only the other day. All those variants have to be monitored, and COG-UK will help us to do that. Nonetheless, they will arise and circulate, and we will probably not recognise them as a problem until they are already relatively well established. We therefore have to find a sustainable way of dealing with that reality.

Thank you. Time is tight, so I will hand back to the convener.

Our next questions are from Beatrice Wishart.

The phrase “vaccine passports” is starting to feature more and more in public discussion, but I want to dig into what is actually meant by it. Some people think that it means having a vaccine before travel, whereas others might understand it to mean needing a vaccine before gaining access to other things that we are currently restricted from doing, such as visiting vulnerable relatives in a care home or going to the pub.

What do you understand by “vaccine passport”, and in which situations might that phrase be used? I go to Professor Griffiths first.

As you say, the phrase “vaccine passports” is thrown around rather a lot, without any real understanding of what it means. The word “passport” tends to imply international travel, or any travel, because that is when we usually use the word in our vernacular.

We can think about vaccine passports in two ways. One way could relate to the ability to travel. For international travel, it may not be a passport; other countries may require us to show some proof that we are immune. At the national level, for use in the community, it would be about the ability to access various places such as theatres, pubs and restaurants.

That is a very broad-brush view—there are many issues to consider. Vaccine certification is extremely complex, and there are ethical issues around inequalities. If vaccine certification was initially about access to care homes, as you said, it would, at this point, mean that younger people would be disenfranchised from visiting their relatives, because they do not have access to the vaccine. They cannot show that they have been vaccinated, because they are not in the groups that should be vaccinated. You might introduce a process whereby people have to be tested, or have proof that they have had the vaccine, before they can go into care homes.

Another issue that comes up, aside from the inequalities, concerns people who will not come forward for vaccination. Will they be disenfranchised from travelling or from taking part in elements of society? All of that would need to be thought through very carefully before you were to talk about mandating vaccine certificates and making them a legal requirement. They could be a voluntary requirement, but that would be very complex.

That is why Michael Gove is heading up a review for Boris Johnson in England to look at the various issues. The Royal Society has published a report, “Twelve criteria for the development and use of COVID-19 vaccine passports”, that lays out all those issues, including the legal and ethical issues that would need to be addressed. A group in Oxford has also produced a report on the topic. There is quite a lot of thought going on, before we rush to say that we must have vaccine passports. It is not as simple as saying, “You’re vaccinated.”

The final point is that, just because you have been vaccinated, that does not mean that you have responded. When we talk about percentages of success, we are talking about a population-based response. It is a very complicated area that could induce more inequalities in a situation that, as I said, already has many inequalities.

I do not have a personal view on the mechanics of creating a vaccine passport and how it would work in practice, because it is not my area of expertise, but I can make some comments on what it might achieve. In Scotland, and in the UK, our whole strategy has for so long been about suppressing the virus, and that has been interpreted to mean that everybody in the population must reduce the number of contacts that they make: the number of times that we meet other people in circumstances in which we might pass on the virus. That means that we have had to restrict activities and day-to-day life in a fundamental way, as we have all seen. There has been much less emphasis on how, rather than restricting the number of contacts, we can simply make those contacts safer.

I am an epidemiologist, and I can say that those two things are equivalent. You can halve the transmission rate of the virus—suppress the virus by 50 per cent—by halving the number of contacts that are made, or by halving the risk per contact. You can work to make those contacts safer. That is what all the personal protective equipment and the hygiene measures, all the barriers that we see in retail and in the hospitality sector that represent the effort that is put in to try to make facilities safe are about: trying to make contacts safe.

We can still have contacts, but they will be safer. They will never be completely safe, just as the vaccine will never guarantee 100 per cent that we cannot get infected and pass the infection on, as Professor Griffiths pointed out. Such measures can do enough, at a population level, to drive down levels of infection without so many restrictions on what we can do.

09:45  

Some kind of notice that says whether someone has been vaccinated absolutely reflects the chances that they will pass on an infection if they have a contact. Incidentally, prior exposure to the virus does the same. It does not provide 100 per cent certainty—there are no guarantees—but it is safer. For example, if I were a vulnerable person in my home and I was having visitors, I would want them to be vaccinated. That would make the contact safer for me, as a vulnerable person—it is logical. That can be done through testing as well—if you test negative, there is obviously more chance that you are virus free. Immunity passports, vaccine passports and negative test results all decrease the chances that a contact will present a risk; they just do not do it to 100 per cent.

I do not feel confident in talking about the mechanics of making that work in practice but, as an epidemiologist, I can say that making contacts safer in that way will have an enormous effect on how well the virus spreads in our communities.

Thank you—that is a helpful response. Perhaps Professor Baker can tell us whether such measures have been discussed in New Zealand.

The two previous speakers summarised the arguments extremely well. In New Zealand, we have not yet had that debate—we are hoping that other countries will resolve those issues for us—partly because the quantity of vaccine for use in our country is not yet very high. Nevertheless, we are watching the debate with a huge amount of interest.

One of the key parameters on which we still await confirmation is the effectiveness of the vaccine in preventing onward transmission. I know that the evidence is starting to firm up on that, and we are assuming that, if there will not be sterilising immunity, there will be something close to it, but we are all waiting to have that confirmed.

My second question is about island communities and the need to treat them differently. That is an on-going conversation in Scotland. I represent an island community, which has lower levels of prevalence than our mainland counterparts. Do you know anything about other island communities and how they have featured in national conversations? I am thinking about what might have happened in New Zealand or Hong Kong.

The analysis of the experience of islands has been very incomplete globally; I have not seen much published work on that. In the Pacific, exclusion of the virus, which is a variation on elimination, is the dominant strategy. That approach is currently protecting about a dozen Pacific island states. As soon as they became aware of the virus, they essentially lifted the drawbridge and put in place robust border control measures. Those were even more robust than the measures in New Zealand, and they have been extremely successful.

However, there are some tragic examples, such as Tahiti and French Polynesia, which in the end gave way to a lot of commercial pressure to open up to tourism, and have hence had quite severe outbreaks. Of course, they then did not get tourists, because tourists did not want to come to a country with an uncontrolled epidemic. Iceland has had some well-documented experiences with varying levels of control at the border. I also understand that a number of islands in Canada and some other places, such as the Channel Islands, have succeeded in excluding the virus entirely.

Professor Griffiths, could I get your view on that?

Hong Kong has quite a large land border with China, but it behaves as an island, in a way. As I said, Hong Kong introduced border controls really quickly, and it moderates the number of people who are allowed in and out, depending on the number of cases that are recorded. It is talking about making a travel bubble with Singapore, which also has island status, although it has a land link. Hong Kong is looking at beginning to try to stimulate tourism and travel by matching up with other countries. However, because it is going for zero Covid, it will want to match only with other places that are currently doing the same.

Hong Kong used to be a global hub, but its economy has really suffered. Some of the airlines there have gone out of business, as flights are down to something like 1978 levels. There is a whole set of issues that go with being an island, and an island that thrives on tourism, and how you should act differently because of that. Hong Kong has gone for very strict monitoring, and it is looking proactively at how it can create new links, in the first instance, with places where rates of Covid are very low.

We need to take an island view, and think about what is happening on our island. I believe that the Scottish road map allows for local variation. Although an area may be in level 3, an island within it could argue for being in level 2, which would allow the tourism industry to restart, if that is an issue.

It is an issue. Professor Woolhouse, do you have any views on that?

I can add a little to the commentaries that we have heard by talking about Scotland’s experience last summer, not just in the islands but across the Highlands and Islands. Tourism was allowed over the summer, albeit in somewhat restricted ways. That experience proved that it is not just opening up access to tourists that counts, but what the epidemiological situation is in the Highlands and Islands or wherever it may be.

Last summer, I heard a lot of voices saying that all the tourists from England were a potential epidemiological threat to the region. I did not think that tourists would be a threat and, as it turned out, they were not. The Highlands and Islands were very busy last summer, as anyone who was in that part of the world will know. I spoke to some people in the hospitality industry there about their situation, and they said that they were very busy. However, there were no outbreaks of any significance that were linked to tourists. There was no epidemiological problem in the Highlands and Islands during last summer’s tourist season.

When the sequencing results came in later in the year, they showed that a small number of lineages of virus could be linked to England—they were not necessarily from tourists, but they could have been. However, that was 6 per cent of the total, so it is clear that that was not where Scotland’s viruses were coming from. It proved possible, last summer, to open up the Highlands and Islands to a significant extent without having a major epidemiological problem. Now that we have the vaccine in place, it is not clear to me why tourism would be more of a problem this summer—if anything, it would surely be less of a problem.

You could wall off the islands if you wished, and stop tourism, but you would have to think carefully about the balance between the public health gain and the loss of income from tourism and other activities if you did that.

Thank you for those answers. The clock is ticking, so we will move on to questions from Annabelle Ewing.

Thank you for joining us. My first question is for Professor Woolhouse. First, I will pick up on the last point and say that I am not aware that anybody is talking about walling off islands. Rather, there is a real desire to see what can be done to ensure that our tourism sector can restart and get on with what it does best.

I will go back to a point that Professor Woolhouse raised at the beginning of the session. He suggested that steps need to be taken by September this year so that we can be confident that the winter of 2021-22 will not be as bad as the winter of 2020-21. Can you outline the specific steps that need to be taken, to that end?

Next winter we want neither a large-scale resurgence of the virus, nor—we absolutely do not want this—any more lockdowns. I think that everyone is agreed on that. We know that the mechanisms that we have in place beyond vaccination reduce the likelihood of our going into lockdown.

Professor Griffiths outlined this in her opening comments, but it is worth underlining. We absolutely must emphasise the importance of self-isolation of cases and their contacts. Next winter, the test and protect system must be working at the best possible level, because there will be outbreaks that we will have to contain through self-isolation. We will have to ensure that people are willing and able to self-isolate when they are required to do so.

In recent months, there has been a lot of talk about the concept of supported self-isolation, which I fully support. That might involve adopting models such as that which is used in New York, where support is so comprehensive that people who are asked to self-isolate are even provided with a dog-walking service. There is much more that we can do to support, and therefore to encourage, people to self-isolate when we need them to do so.

Secondly, we must, in the first place, actually find the people who need to self-isolate. That is critical. My group has done some work on this, as has Health Protection Scotland, and work has been done in England, where the results were similar. Current estimates show that we are finding fewer than half of cases; the numbers that are reported by the Government every day represent fewer than half the number of cases that are occurring in Scotland. That assessment is very well validated by active surveys by the Office for National Statistics on how much virus is present, which give us the one in 100 or one in 150 figures that we see. Those surveys confirm what I have just said: that we are probably not finding even half the cases in Scotland. It is as though we are fighting the epidemic with one hand tied behind our back. We cannot assume that all those cases are self-isolating, and it is clear that their contacts are not all being traced. Our main weapon for suppressing transmission of the virus is only working half as well as it should be, because we are not finding the cases in the first place.

Those people are not coming forward voluntarily, so there are a couple of ways in which we can find them. An interesting recent study showed that a lot of people did not know that they had Covid-19. Some cases were genuinely asymptomatic—they had no symptoms. I will come back to those in a minute. Some, however, simply had the “wrong” symptoms—not the symptoms that NHS 111 or whatever advertises that we should report—so they did not recognise what they had. There is a little bit of disagreement among epidemiologists as to how much difference it would make, but it is clear that if the categories of symptoms were to be broadened so that we caught those cases, that would make some difference.

The asymptomatic cases are very difficult. The only way we have of catching them is through active mass testing. I hope, therefore, that by September we are much more committed to testing in the community on a larger scale than we have been doing, even though the technology has been available since last November. That will help enormously. I describe the approach as “test on request”—people who are likely to do something that might involve contact with cases and could spread the virus should be tested first.

Such testing is how the Scottish Premier League football clubs manage to undertake their day-to-day activities. We could extend that approach much further to catch many more cases, in particular in high-risk settings. We need to build on self-isolation and on testing, which are the essential pillars of a sound response for next winter.

I thank Professor Woolhouse for that comprehensive and interesting response.

I will bring in Professor Baker, and then Professor Griffiths. After they have spoken, perhaps Professor Woolhouse can come in on my next question, to which his expertise is relevant.

Face coverings and 2m social distancing are currently part of our lives, day and daily. Many people are asking whether that is the future, or whether there is any possibility—and if so, within what rough timescale—of relaxing those measures. Professor Baker, what is your view on that?

10:00  

In New Zealand, we currently have quite a different context and a different goal, which means that we use the approaches differently. At present, we have no circulating virus, so all the emphasis is on our borders, and—in the event that there is a border breach—on our back-up systems, which include very high-volume testing in the community. New Zealand is now in the position in which a single case in the community is headline news and results in a very intense response. The context is so different.

As we have come to understand the virus better—in fact, tomorrow it will be exactly a year since the virus first arrived in New Zealand—we have moved from using crude methods such as very strong border shutdowns or quarantines and intense lockdowns to our current four-levels system, which includes sub-levels. We can now use high-volume testing, contact tracing and a lockdown that is not really a lockdown at all—it is about stopping spread with physical distancing and use of face masks. That approach is selective and works very well, but you have to have the two together. What Professor Woolhouse described is a logical progression from that, but we still need the other measures. We still need an alert level—that is what we call it in New Zealand—to dampen down transmission so that the contact tracing system is not overwhelmed. However, it has not been overwhelmed for the best part of a year now.

I lived for many years in Hong Kong where, post the 2003 SARS outbreak, if a person has an upper respiratory tract infection, they wear a mask. If you have the sniffles, you wear a mask and go to work. It is a different way of thinking.

There has been a big scientific debate about mask wearing. The World Health Organization supports the use of face coverings. The US is now talking about doubling up on face coverings, but its virus rates are currently very high, so there is a sense in which it is also about messaging. We all saw the politics around President Trump and masks. There is the science, and then there is the politics of masks, which is very much culturally determined. As soon as the coronavirus epidemic started in China, there were queues at all the shops in Hong Kong that sold masks, and they ran out very quickly, because the population sees masks as being protective. The science supports that—Ben Cowling, at the University of Hong Kong, has looked intensely at that.

Masks are not foolproof; wearing a mask does not mean that one is not passing on the virus or will not catch it, but it can reduce the chances of transmission between two people who are wearing them. Mask wearing has been quite a contentious issue. For some reason, we have not been promoting it in UK culture in the way that other countries have. The future of masks might be something that the population decides on, as opposed to their use being mandated. We do not mandate masks as other places have, as part of their social distancing and personal protection approach.

There are interesting questions. When are masks mandated? When do you have to wear them? Who will continue to think that masks are useful, and who feels more protected when they wear one? There is some evidence to show that it is true that people do.

On social distancing measures, it is very difficult to know what will happen. The road map that was given in England said that we would be back to normal on 21 June, but there will be a review at that point. The problem is that we are all looking at dates as opposed to data. Some of us would prefer to see the data.

A review group will look at all the evidence and make recommendations. I have heard other very senior scientists say that they think that we will perhaps still be wearing masks next winter in situations in which people are in close contact, such as in shops. It is difficult to give an absolute answer to the question, but I stress that there is quite a large cultural element involved; it is not all pure science. It will be about what seems to fit as we move forward. If we can keep vaccination rates high and transmission low, we will avoid more lockdowns. Essentially, the question is about what it takes to do that. Will masks and social distancing play into the approach?

I agree that there is need for a very good test and trace system and for support for people who are in self-isolation. That will be fundamental. To go back to inequalities, I note that we know that many people, in particular those on zero-hours contracts, do not want to come forward because they do not want to lose their income. We have to make suppression of the virus possible and practical for the whole of our population.

I must apologise, convener—I have to go to a meeting in Wales now, so I will have to leave you all. I am sorry about that. Thank you for listening to me today.

Thank you very much indeed. I appreciate that my time seems to be up, convener, but if Professor Woolhouse wants to return to masks in a later discussion with one of my colleagues, I am sure that he will be welcome to do so.

I am sure that Professor Woolhouse will be able to answer your question when he addresses other questions. I take the opportunity to thank Professor Griffiths for her attendance.

Our next questions are from John Mason.

This question might be for Professor Baker, but I will be guided by whoever wants to answer it. The question of costs and benefits has been mentioned; for example, we discussed the need to balance tourism with keeping the virus out. We have been told about the idea of quality-adjusted life years and putting a cost on such things. I am an accountant, so I quite like the approach, but I also feel that it is a bit hard-hearted, in some ways.

I understand that, normally, we would give somebody a drug if the cost, based on their QALY score, was between £20,000 and £30,000. It has been suggested that the cost for saving a life from Covid is much higher, at £200,000 or more. Should we look at things that way? Is it a useful approach?

That is a great question. When I talk to health economists about the matter, they generally say that we will know only with hindsight how the economics stack up. However, we cannot look at pandemic control using standard health-intervention measurements such as you describe—for example, if we were to say that an intervention had to stack up with the cost per QALY, or whatever measure we were using. In conventional economic terms, we are talking about very expensive years of life being saved as a result of the Covid response. Some people might say that the better metaphor is that Chamberlain, when deciding whether to declare war after Germany invaded Poland, would not have looked at the QALYs or disability-adjusted life years that would be saved. Similarly, there is a different metric when we are battling something like Covid. It is not a major existential threat, but it is a threat that we cannot fully quantify.

In addition, with regard to negative effects, we need to look at alternative scenarios. It is often better to ask what scenario we would choose, and what scenario a population would choose. In New Zealand, even though the Covid response is the most expensive public health intervention in our history, there is a massive mandate for it; our Government was returned with the highest majority since we introduced proportional representation. Based on willingness to pay, I think that such intervention is, according to that metric, highly supported.

Nevertheless, that was a very good question. I suspect that we will see the answer only with hindsight.

Perhaps Professor Woolhouse wants to comment on that point.

I agree with what John Mason said in the question. Your assessments are right, and there is a real prospect that the Covid response will turn out to be one of the most costly public health interventions in history, in terms of price per life saved, or however you want to keep score.

However, I agree with Professor Baker that this is not a situation in which we should apply standard health economics metrics. The figure of £20,000 to £30,000 per healthy life year that you gave comes from the National Institute for Health and Care Excellence, which is charged with working out how much we should be spending on individual patients in the national health service.

That is important, but there is an even more important question underlying what you said. Is it possible for the cure to be worse than the disease? Yes, it is. We will have to make a reckoning of that after the event is over. In fact, that has already started. As far back as April last year the ONS did a study for the scientific advisory group for emergencies down in London, and its assessment was that the indirect harms of the first lockdown, in terms of morbidity and mortality—it used the QALY measure that was mentioned—were, in its central estimate, three times higher than the benefit. It estimated that the harm that was done by lockdown was so huge that it outweighed the public health benefit.

There is a lot of uncertainty about that, and the ONS has done a second analysis more recently—which, I have to say, is even more equivocal about where the balance truly lies. Nevertheless, it is clear that there is genuine concern that the cure has, in fact, been worse than the disease. We might find out that that is the case.

I guess that we will know some of that only in hindsight.

I want to touch on how prepared different countries were for a pandemic. There had been expectations of a pandemic and it was suggested that the UK and the US were the best-prepared countries, yet they have had huge levels of deaths and infections. On the other hand, I do not know how well prepared New Zealand was, but it has certainly been very successful. Is it possible for us to be better prepared for pandemics in the future?

As you know, the UK, including Scotland, was prepared for pandemic influenza in particular. That was not the only focus of our preparedness planning—I have discussed other potential threats with chief medical officers in the past—but nonetheless the detailed preparations were for pandemic influenza.

In south-east Asia, the situation was different. I would love to know what the situation was in New Zealand. South-east Asia was much more affected by the SARS epidemic in 2003, so preparations there were around SARS. Most global public health specialists and epidemiologists would say that there is a clear dichotomy: those countries that were prepared for SARS on the back of what happened in 2003 did better than countries such as the UK, including Scotland, and the US, which had prepared for pandemic influenza.

As we have heard, New Zealand has been very successful, but arguably Taiwan has been the most successful country of all during the pandemic. Taiwan started its SARS-motivated response on 31 December 2019, when it first heard what was happening in China. That was before most people in the UK had even heard of the virus or the disease. I have concluded from that comparison that, although it would have helped if the UK or Scotland had been better prepared, we needed to be better prepared for the right thing.

There are actions that were not taken back in January 2020 because we were implementing the best preparedness plans that we had, which were based around influenza. We should have been preparing more widely and years before that for things that are not influenza, including the virus that we are actually faced with. As I like to put it, we did our homework but, when we were given the exam, it was the wrong test.

That is a good comparison. Does Professor Baker want to come in?

I agree with Professor Woolhouse on that. In fact, New Zealand was poorly prepared. The main thing that we did right was that we looked at the experience of China and Taiwan in particular and thought, “This virus can be contained.” It was contained very effectively in Wuhan—the “Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19)”, which came out at the end of February, said that that was the case. The WHO went in with a credible group of scientists and they said that the virus really had been contained.

It is a remarkable and unprecedented achievement that a respiratory virus pandemic could be stopped when it was already very intense. People like me said, “It’s more like a SARS virus and less like influenza. We won’t tear up our influenza plan, but we’ll apply it in reverse order. We’ll throw everything at the virus at the beginning, rather than taking the mitigation approach and gradually increasing the intensity of the response as the pandemic worsens.” When we had fewer than 100 cases in New Zealand and no deaths, we went into our most intense lockdown to eliminate the virus. We were following the Chinese model.

10:15  

I must admit that I assumed that the entire western world would do the same. Admittedly, New Zealand had a slight timing advantage, but it was not profound. Unfortunately, the WHO was telling us to do almost the opposite: it was saying, “Keep your borders open, save lockdowns as a last resort and don’t divert masks for widespread use—save them for the health workers.” In the end, we simply did the opposite of what the WHO was recommending, and that is what helped.

By all metrics of preparedness, New Zealand was quite a long way down the list in terms of resources. At the top of the list were the US and the UK. I am still greatly surprised that the western world ignored the experience of China and that the WHO, which was tracking events in China—it was partly a WHO team that went in there—did not seem to follow its own evidence. The failures of risk assessment will be picked over for many years in order to understand why most western countries got it so wrong at that point.

My first question is for Professor Woolhouse. You have given us an upbeat view of progress, in that we are ahead of the Scottish Government’s original plan for relaxing lockdown. However, we still have pockets in which there is an increase in cases, such as the Lothians, Dunbartonshire and Stirling. Is the view that you have taken sensible, bearing in mind the current situation in those areas?

The epidemic has always been heterogeneous in Scotland. That has always been an argument for targeting measures at specific regions such as local authority areas, health board areas or whatever, and the Scottish Government has consistently done that, which I think is quite appropriate.

I think that we would all agree that, if measures can be taken locally rather than nationally, we all benefit, so I have no difficulty with the Scottish Government taking great notice of any local variations in the state of the epidemic.

Yes, but your upbeat view—which is good to hear, of course—rather concerns me in relation to the local issues in those areas, which we heard about earlier this morning.

I am agreeing with what I understand the First Minister to have said: that there may be different rates of relaxation in different areas. I agree with that.

Okay—thank you for that.

I turn to Professor Baker. What key points have you learned in New Zealand as a result of the epidemic? Which measures should we implement in Scotland, and possibly across the UK?

My main conclusion is that you need informed scientific input and decision makers who listen to scientists and act decisively. It is frustrating to have one without the other—to not have the science correct or not have the political leadership. You also need some other elements, such as enough infrastructure to implement measures; engagement and trust from the public; and some kind of safety net to protect the most vulnerable. Those five elements seem to be critical.

There are now about 15 jurisdictions around the globe that are pursuing elimination. It is the dominant model across the Asia-Pacific region, and it has been highly effective. As Professor Woolhouse mentioned, many of those Asian countries had experience of SARS. We have done a lot of work with Taiwan and we published a paper in one of the Lancet journals in which we outlined what New Zealand did and said that Taiwan actually did it even better.

Taiwan had a dedicated agency that looked at what was happening and acted swiftly early on. It entirely avoided the need for a lockdown, and it did so partly by managing its borders very carefully. In addition, it had an established culture of mask use and established contact tracing systems in place. All those elements came together to form the best response—I think—in the world, based on outcomes, with the least amount of disruption. For future preparedness for respiratory pandemics, we could learn a lot from what Taiwan did.

Thank you for that. I come to my final question. With regard to leadership, is it the health experts, rather than the politicians, who lead at times like this?

We need a collaboration involving both. I have been one of the science advisers in New Zealand and I think that, ultimately, our task is easier. There is the fear of being wrong, which is quite difficult and stressful for scientists, but in the end it is the elected politicians—the representatives—who have to make the really tough calls, based on the science advice and the economic and other consequences. They have the hardest job, and they will suffer electorally if they get the balance wrong.

In New Zealand, our leaders got it right and, as a result, they had a very positive endorsement from the public in our November election. We need mechanisms that allow the scientists and the politicians to have a frank and positive relationship in order to undertake risk assessment and identify risk management options.

I have a question for both of the remaining witnesses. Later this year, the Euro 2021 football championships will take place. As we have heard from both the Prime Minister, earlier this week, and the First Minister, the indications are that the vaccine programme for adults will not be completed until some point in July—that is certainly the target date. However, the Euro championships will start in June—the first game in England will take place on 13 June, with some other games in London and Scotland thereafter.

Bearing it in mind that every country has its own vaccination programme and that programmes will be delivered at different rates, what do you think about opening up football stadia when the whole adult population has not yet been vaccinated? Will it be safe to allow football fans into stadia and people to travel from one country to another?

It is a question of doing the work and undertaking a formal risk assessment to look at the risks that are involved in partially opening stadiums, opening them only to fans in Scotland or whatever the various options might be.

We know that the virus transmits best in particular environments, such as when adults are gathered together indoors for prolonged periods in poorly ventilated conditions, especially when they are talking. That is a description of what we do in our houses, which are the best place for the virus to transmit. Mass gatherings are clearly a problem because people may be packed closely together and because there are pinch points such as travel, toilet and refreshment facilities and so on, where conditions may be better for enabling the virus to transmit.

Decisions would have to be made on the basis of a proper risk assessment. To be frank, I do not think that any of us can say just yet with complete confidence what the epidemiological situation will be in June. That brings me back to my original comment in response to a previous question. The data look very good, and we should maybe think about bringing things forward, but that is part of the risk assessment. If things are continuing to go better than we had expected, one would hope that the risk assessment would be more positive. A glib answer of yes or no from me would not be appropriate—you would have to do the work.

I am not sure that I can add much to that. It is a problem for risk assessment, and you are all much closer than I am to the situation that will apply. I guess that a lot will come down to how effective the vaccines are at interrupting transmission. We always think that the combination of people travelling internationally and large gatherings are two huge red flags for transmission of the virus, so it is quite a tough question.

I do not know enough about the exact timing of what you are going to be doing, but I think that everyone will want to be very cautious throughout the coming year. I have heard that view expressed a lot, certainly in this part of the world. Again, however, the UK is ahead of New Zealand on vaccination, so perhaps things will be such that you can be more optimistic part way through the year.

My second question is on a different subject. We have already discussed today areas of deprivation. The area that I represent is considered to be deprived, and we also have an ageing demographic. To give you an indication of that, the National Records of Scotland says that, between 1998 and 2019, the 75-plus age category increased by 24 per cent, the 65 to 74 age group increased by 13.8 per cent and the 45 to 64 age group also increased by 13.8 per cent. In contrast, the younger population is very much decreasing. A specific example is the 25 to 44 age group, which has decreased by 29.1 per cent.

Given the deprivation challenges that we face, along with our ageing demographic, is a perfect storm of challenges facing particular communities, mine included, as a result of the effects of Covid and how it is dealt with?

There is overwhelming evidence that there is a huge gradient based on age, deprivation, ethnicity and co-morbidities—there are multiple factors that are now quite well established. Considerations around equity are huge in driving interventions and concern for particular populations. There are many global examples of countries that have not paid enough attention to equity, and that has derailed their programmes. Singapore is one of the best-documented examples.

In all aspects of the response, equity needs to be put right at the centre. One of the reasons why New Zealand was so enthusiastic about the elimination approach was that we knew that keeping the virus out would be the most pro-equity policy that we could have. There was huge concern to keep the virus out of the Pacific islands, to which people travel from New Zealand, in order to protect those countries. That has been a big driver here. We have not seen any social gradient in New Zealand because we have not had many cases, but ours is obviously not a typical situation.

Equity is tremendously important. As the committee knows well, health inequities have been an issue in Scotland for generations. One of the inequities that has come to light concerns access to health care, and a spotlight has been shone on that through the issue of access to and uptake of the vaccination programmes. I put it in this way: if there was ever a motivation to try to iron out those long-standing inequities, uptake of vaccines would surely be it.

There is a double effect. We want to protect the people who, as Stuart McMillan rightly said, have an increased vulnerability to the virus, so that has to be an imperative. We also want to protect the entire population, which we cannot do if there are pockets of the population where the virus is circulating freely because vaccine uptake has been low. That is a tremendous motivation for trying to sort out those long-standing inequities.

My final question is brief. We have heard the phrase “data not dates” being used over the past few weeks. Which data should be driving the strategic response? Should it be prevalence, incidence, the R number, the positivity rate or vaccine coverage? I put that question to Professor Woolhouse first.

10:30  

The vaccination programme has the very strong effect of decoupling the burden on the NHS from the incidence and from the R number. For example, in the next few weeks, it will be possible—I am not saying that this will happen—for the R number to be above 1 and for the number of hospitalisations still to be going down, because the vaccine roll-out is more than compensating for any increase in the number of cases. Those metrics—the incidence and the R number—will become less important.

We would want to pay attention in particular to hospitalisation rates and to the age distribution in those rates, and also to not only the number of vaccinations that have been given—the rate of roll-out—but the figure for coverage, which came up at the beginning of the session. We want the coverage to be as high as possible. That relates to my answer to your previous question. We want even the people who do not normally get good access to health services or do not take up vaccines to take up this one, because the higher the coverage, the more we are all protected.

The numbers that we want to watch have changed. The WHO’s test positivity rate has not been a good indicator of the state of the epidemic in Scotland all along. I have yet to discover from the WHO where it came up with the 5 per cent figure, but it does not seem to have much bearing on what is going on in Scotland, and it has not been a good indicator for us. Hospitalisation rates and vaccine roll-outs are my priorities.

I very much defer to Professor Woolhouse on that question, because we do not have experience in New Zealand of dealing with the issue of which indicators to use. We would obviously have used all the indicators that have been described if we had transmission within New Zealand.

Thank you very much, gentlemen.

I have only one question, but it is for both Professor Woolhouse and Professor Baker. I want to give you a wee opportunity to sum up by saying what we should do next and what would give us the greatest return.

Professor Woolhouse, I found some of your comments quite worrying. You said that Scotland could never get to where New Zealand is now, that 75 per cent of people were infected after the lockdown measures were introduced, that we are on a knife edge in terms of suppressing the new variant and that we are finding only half of the people whom we need to self-isolate.

As a constituency member for Kilmarnock and Irvine Valley, I see constituents going in and out of supermarkets and retail parks day in, day out. There is no track and trace going on in those places, as far as I can see. Do we need to wise up with regard to the technology that we use to do that? Is that perhaps one of the areas where we can make the greatest impact as we move forward in trying to suppress the virus?

There has been a lot of talk about the uptake of the apps that allow us to track and trace, which has been quite low. As a consequence, the contribution of the apps to reducing transmission has been even lower. If only half of the people take up the app, it will be only a quarter as effective—we require both parties to have the app in order for it to work. In south-east Asia, there has been much more enthusiastic and regulated use of apps to try to monitor the virus. That requires uptake, and mechanisms to encourage and enforce uptake. The uptake must be very high if the apps are to make a substantial difference.

To broaden my answer, I note that all the problems that I have reported, which you described, are about trying to suppress the virus. Once the virus is established, that only gets us so far, as we have seen in Scotland and the UK, and in the whole of western Europe.

I have one small issue with a comment that Professor Baker made a few questions ago. He said that there were marginal differences in the timing of New Zealand’s response to the epidemic. No—those were decisive differences. New Zealand was able to take its actions when it did, with the effect that those actions had, because the virus was not already established there. I come back to the point that, in the UK and in Scotland, we would have had to take those actions probably in mid-February, and that was not being discussed at the time. Once the virus is established, suppression does not solve all the problems that you, I and everyone else want to solve. We have to do more.

Professor Baker, will you offer a few words? Where is the greatest opportunity for us to make the greatest impact on reducing or suppressing the virus?

I should be very humble in giving advice to Scotland, because I do not know all the conditions that apply there. Again, I am very interested in Professor Woolhouse’s comments as he is there, on the spot, having to look at the situation.

I am interested in the idea of path dependency. Countries chose their major approaches early on and decided to head down particular valleys. Once you are heading down a valley, it may be quite hard to cross over to a different one.

I have not done enough comparative modelling of the scenarios in different countries. What convinced me early on with regard to our elimination strategy was simply that Wuhan, which had the earliest and most intense epidemic anywhere, was able to contain and eliminate it. That provided me with a lot of reassurance that, given that conditions in New Zealand were more favourable than in Wuhan, we should be able to manage elimination. We were not certain that we could do that, and in a sense it is still an open question.

I think that a country can change its trajectory from a suppression approach to elimination even many months after the virus has been introduced. When I talk to modellers, they say that there is no specific barrier to doing that. Essentially, with lockdown, the use of masks and so on, you are basically putting the population into home quarantine for several weeks. Most modelling that I have seen done shows that you can eliminate the virus from almost any starting point; it is just a question of whether other preconditions exist, or whether conditions make it very difficult.

I cannot really comment on how that would apply in the Scottish context, but availability of effective vaccines should certainly make elimination easier. Around the globe, we have elimination strategies for viruses that are far more infectious, such as measles. That is why, personally, I still believe that it is worth considering elimination, before it is rejected by your organisations in Scotland.

Thank you for those answers. In the interest of time, I will hand back to the convener.

I am grateful to you, Mr Coffey, for shortening your questions slightly and drawing the session to a close. I thank Professor Baker and Professor Woolhouse for speaking to us this morning and taking our questions. It has been an incredibly helpful session.

That concludes our consideration of agenda item 1. I will suspend the meeting to allow a changeover of witnesses.

10:38 Meeting suspended.  

10:45 On resuming—