Transparency data

SAGE 48 minutes: Coronavirus (COVID-19) response, 23 July 2020

Published 25 September 2020

Forty-eighth SAGE meeting on COVID-19, 23 July 2020.

Held via Video Teleconferencing.

Summary

1. A significant and growing proportion of the epidemic in much of England (newly reported cases) is now among South Asian populations, despite these groups making up only 8% of the whole population. The epidemic among white populations continues to decline but it may well be flat among South Asian populations.

2. SAGE noted the risk that lessons from Leicester and PHE data on other outbreaks could be misinterpreted and lead to increased stigma. Public messaging around these should be well contextualised.

3. Communication which is culturally appropriate and relevant may promote health protective behaviours, which can reduce the risk of COVID-19 in BAME communities. Local authorities should build partnerships with key community members to help address this ahead of winter. These issues need active consideration by policy leads across HMG.

4. SAGE advised that segmentation by age is not without considerable risk and is unlikely to be successful.

5. SAGE endorsed the EMG paper on airborne transmission, noting its findings around the limitations of face shields/visors and on the importance of good ventilation.

Situation update

6. SAGE agreed it is for PHE experts to determine whether an in vivo animal study into co-infection of SARS-CoV-2 and influenza would give meaningful results; SAGE is supportive if a strong case is developed and the study can be conducted ahead of the winter season.

7. SAGE endorsed the EMG paper on airborne transmission, noting its findings around the limitations of face shields/visors in preventing transmission (as used, for example, by hairdressers) and on the importance of good ventilation (especially in higher-risk settings such as dental and GP surgeries).

8. SAGE approved R and growth estimates. The latest estimate of R for the UK is 0.7 to 0.9, while the daily growth rate estimate is -4% to -1%. In England, R is estimated at 0.8 to 1.0, with a daily growth rate of -4% to 0%. As previously, SPI-M does not have confidence that most regional R estimates are sufficiently robust to inform decisions, since they are based on low case numbers and/or are dominated by clustered outbreaks.

9. It was noted that models which use case data and emergency call data (both contemporary indicators) currently give higher estimates for R and growth rates compared to those using deaths data (a lagging indicator) — and that the former may offer early warning of changes in transmission.

10. SPI-M is continuing to investigate the impact of test accuracy on modelling outputs.

11. CO-CIN data indicate that people with HIV are requiring greater levels of intensive care and are at increased risk of dying from COVID-19. This is consistent with the evidence previously considered at SAGE.

12. Recovery of viable virus from individuals in days 7 to 10 after symptom onset is informing thinking by the Senior Clinicians Group about changes to advice around self-isolation for individuals with swab-proven COVID-19, and to advice around testing and release of contacts.

13. There has been one confirmed case of a cat in the UK with COVID-19. Advice with regards to risk of transmission from pets is unchanged.

Actions:

• PHE to decide whether to take forward in vivo animal study into co-infection of SARS-CoV-2 and influenza
• SAGE secretariat to send ‘Role of Aerosol Transmission in COVID-19’ paper to HSE, PHE, BEIS, dCMOs and Devolved Administration representatives, highlighting advice on face visors and ventilation, by 24 July
• SAGE secretariat to circulate, once available, CO-CIN HIV paper to Senior Clinicians Group, PHE and Devolved Administration representatives for consideration of public health action
• CMO to outline process for reviewing advice on confirmed case isolation period, drawing on previous SAGE advice on infectiousness and testing, by 30 July

Segmentation

14. SAGE endorsed the latest SPI-M paper on age-structured segmentation, subject to minor revisions.

15. It was noted that there has been a large reduction in contacts compared to pre-lockdown levels. However, CoMix studies indicate that individuals aged >40 years still have a relatively high proportion of contacts among those aged <40 years due to household age structures. Around two-thirds of people in the UK live in a household which includes one or more individuals aged 45 and above. Any segmentation based on this age threshold would therefore affect most households.

16. It is important to note that household structures differ between different ethnic and social groups and this has implications for the effects of any proposed segmentation approach.

17. Age-based segmentation would also raise ethical issues and wider welfare concerns. Although under 45s are at less risk from COVID-19, including lower risk of death, they are nonetheless at some risk and long-term sequalae are not yet well understood.

18. On these grounds, SAGE advised that segmentation by age in this way (around age 45) is not without considerable risk and is unlikely to be successful in reducing mortality and morbidity. This will be reviewed as new data emerge.

Identifying outbreaks, including lessons from Leicester

19. Evidence shows that increasing swab positivity rate (>5%) is a good indicator of a potential outbreak.

20. The Leicester outbreak has demonstrated the value of genome sequencing in understanding drivers of transmission: analysis suggests high transmission within households which may be related to inter-connectedness of families. It has also identified phylotypes particularly prevalent in some Asian ethnic groups and some prevalent in the white British group.

21. SAGE noted the value of the daily PHE sitrep, which has observed outbreaks among seasonal workers, asylum seekers in the North East, and the traveller community. As SAGE has previously discussed, the food handling sector is over-represented (meat packing, fish processing, supermarkets), as are some retail settings linked to warehouses. Outbreaks in outdoor settings are occurring, but this is more likely associated with living conditions among workers.

22. The data contained in the PHE sitrep may enable identification of superspreading events and improve understanding of how and where these occur.

23. More broadly, SAGE noted COVID-19 has followed a familiar path to previous large epidemics in which it proves challenging to reduce incidence among harder-to-reach populations.

24. A substantial and growing proportion of the epidemic (newly reported cases) in England is now among South Asian populations despite these groups making up 8% of the whole population. The epidemic among white populations continues to decline — though southern and eastern European groups remain at risk — but it may be flat among South Asian populations.

25. The Leicester outbreak is across a reasonably wide geographical area. It has not translated into a significant increase in hospital admissions and has not caused increased substantially increased mortality, although this could change.

26. SPI-M has concluded that the age distribution of cases in Leicester is in line with expectations, although there is a possibility that cases have been missed among older age groups.

27. The citizens of Leicester responded well to the re-imposition of measures: there was a significant reduction in footfall and road and public transport use. As with other hotspots, there has been some reluctance for cases in the community to identify themselves, and challenges around contact tracing.

28. SAGE noted the risk that lessons from Leicester and PHE data on other outbreaks could be misinterpreted and lead to increased stigma. Public messaging around these should be carefully handled and well contextualised.

Actions:

• John Edmunds to establish CoMIX study focused specifically on UK South Asian populations

Targeted messaging for BAME and hard-to-reach groups

29. SAGE endorsed the SPI-B consensus paper on BAME communication.

30. Communication which is culturally appropriate and relevant may promote health protective behaviours, which can reduce the risk of COVID-19 in BAME communities.

31. Health messaging which considers a group’s capability, opportunity and motivation is likely to be more effective; these are likely to differ across and within groups.

32. SAGE noted the importance of ensuring that health messages explicitly consider cultural norms (for example living in multigenerational homes) and recognise disadvantages to the target community (loss of income due to self-isolation).

33. SAGE also noted the importance of considering the different impacts of COVID-19 on BAME communities. Advice and guidance will need to vary in this respect as well.

34. Translating health messages into different languages is necessary, but is unlikely to be sufficient on its own. There is a risk that translation changes the meaning of core messages and therefore co-production and testing of health messages with target communities is essential.

35. Local authorities should build partnerships with key community members to understand cultural norms and barriers, to help tailor communications and to draw on them as trusted sources of advice. This engagement should be done ahead of winter.

36. These issues need active consideration by policy leads across HMG.

Actions:

• SAGE secretariat to circulate ‘SPI-B Consensus on BAME communication’ paper to DHSC, PHE, MHCLG, CO and Devolved Administration representatives, and to all CSAs for dissemination within their departments by 24 July; SAGE secretariat to consider other approaches to communicating contents across government, such as an online seminar
• SAGE participants to send suggestions for chair and participants of small group to consider epidemiology and communication in South Asian communities to SAGE secretariat by 27 July; SAGE secretariat to establish this group in discussion with policy leads in CO, DHSC and MHCLG

Excess deaths and reasonable worst-case scenario

37. SAGE endorsed the ONS paper on excess deaths and morbidity paper, noting both direct and indirect impacts arising from the pandemic such as improved air quality but also increased domestic abuse, mental ill health and cardiovascular problems.

38. Understanding of morbidity associated with COVID-19 will emerge over time as we learn more about long-term health effects.

39. SPI-M has carried out preliminary modelling of a range of scenarios which are designed to support planning, covering the period mid-July 2020 until the end of March 2021. These are not forecasts or predictions and are subject to significant uncertainty.

40. It is unlikely that the epidemic will progress evenly across the UK; instead, numerous localised outbreaks could develop into regional outbreaks.

41. Due to the nature of the scenario modelled, regions that currently have low incidence may have smaller modelled epidemics than regions with higher starting incidence. This may not happen in practice.

42. SAGE will review further modelling of these scenarios at its next meeting.

Actions:

• SAGE participants to send any further comments on draft scenarios to SPI-M chairs by 24 July; SPI-M to produce a finished reasonable worst-case scenario in response to the commission

Next meeting

43. This will include items on JBC trigger points, reasonable worst-case scenario and MHCLG commission on local lockdowns.

Actions:

• SAGE secretariat to confirm timings of SAGE meetings during August by 24 July

List of actions

• PHE to decide whether to take forward in vivo animal study into co-infection of SARS-CoV-2 and influenza
• SAGE secretariat to send ‘Role of Aerosol Transmission in COVID-19’ paper to HSE, PHE, BEIS, dCMOs and Devolved Administration representatives, highlighting advice on face visors and ventilation, by 24 July
• SAGE secretariat to circulate, once available, CO-CIN HIV paper to Senior Clinicians Group, PHE and Devolved Administration representatives for consideration of public health action
• CMO to outline process for reviewing advice on confirmed case isolation period, drawing on previous SAGE advice on infectiousness and testing, by 30 July
• John Edmunds to establish CoMIX study focused specifically on UK South Asian populations
• SAGE secretariat to circulate ‘SPI-B Consensus on BAME communication’ paper to DHSC, PHE, MHCLG, CO and Devolved Administration representatives, and to all CSAs for dissemination within their departments by 24 July; SAGE secretariat to consider other approaches to communicating contents across government, such as an online seminar
• SAGE participants to send suggestions for chair and participants of small group to consider epidemiology and communication in South Asian communities to SAGE secretariat by 27 July; SAGE secretariat to establish this group in discussion with policy leads in CO, DHSC and MHCLG
• SAGE participants to send any further comments on draft scenarios to SPI-M chairs by 24 July; SPI-M to produce a finished reasonable worst-case scenario in response to the commission
• SAGE secretariat to confirm timings of SAGE meetings during August by 24 July

Attendees

Scientific experts

• Patrick Valiance (GCSA)
• Chris Whitty (CMO)
• Alan Penn (CSA MHCLG)
• Andrew Curran (CSA HSE)
• Andrew Morris (Scottish COVID-19 Advisory Group)
• Angela McLean (CSA MOD)
• Atiya Kamal (Birmingham City)
• Ben Humberstone (ONS)
• Calum Semple (Liverpool)
• Catherine Noakes (Leeds)
• Charlotte Watts (CSA DFID)
• Ian Boyd (St Andrews)
• Ian Diamond (ONS)
• Ian Young (CMO Northern Ireland)
• James Rubin (KCL)
• Jenny Harries (dCMO)
• Jim McMenamin (Health Protection Scotland)
• John Aston (CSA HO)
• John Edmunds (LSHTM)
• Jonathan Van Tam (dCMO)
• Julia Gog (Cambridge)
• Lucy Yardley (Bristol)
• Maria Zambon (PHE)
• Mark Walport (UKRI)
• Mark Wilcox (NHS)
• Matt Gurden (Government Actuary Department)
• Michael Parker (Oxford)
• Nicola Steedman (dCMO Scotland)
• Peter Horby (Oxford)
• Rob Orford (Health CSA Wales)
• Sharon Peacock (PHE)
• Sheila Rowan (CSA Scotland)
• Stuart MacDonald (Institute and Faculty of Actuaries)
• Tom Rodden (CSA DCMS)
• Venki Ramakrishnan (Royal Society)
• Wendy Barclay (Imperial)
• Yvonne Doyle (PHE)

Observers:

• Vanessa MacDougall

Secretariat:

• Simon Whitfield
• Stuart Wainwright

Total: 63

1 scientific expert, 8 observers and government officials and 14 Secretariat members redacted.