COVID-19 - guidance for health protection teams (HPTs)
Version 2.3
- Version
- 2.3 Show version history
- Published
- 21 June 2022 (Latest release)
- Type
- Guidance
- Author
- Public Health Scotland
- Coronavirus (COVID-19)
- Health protection
Purpose and scope
This guidance is for staff working in health protection teams (HPTs) and healthcare settings across Scotland.
It supports staff managing coronavirus disease 19 (COVID-19).
Using this guidance
The guidance supports, but does not replace:
- individual expert clinical judgment
- local response arrangements
The guidance supports maintenance of agreed health protection principles and national policy in line with the Public Health etc. (Scotland) Act 2008 including:
- exercising functions to encourage equal opportunities
- observance of equal opportunities requirements
Employers should consider specific conditions of each place of work and follow the Health and Safety at Work etc. Act 1974 and other appropriate legislation.
Related resources
This document should be read with these related resources.
Health protection team contacts
Access up-to-date contact information for local HPTs.
Introduction
The disease COVID-19 is caused by severe acute respiratory syndrome coronavirus 2, also known as SARS-CoV-2. SARS-CoV-2 is a ribonucleic acid (RNA) virus.
The first cases of COVID-19 in the UK were detected on 31 January 2020.
The World Health Organization (WHO) declared COVID-19 as a pandemic on 12 March 2020.
Transmission
SARS-CoV-2 is spread by respiratory particles. It occurs mainly through close contact with infectious individuals.
Transmission risk increases:
- when people are close to each other (usually within 2 metres)
- in indoor, poorly ventilated environments that are not regularly cleaned [1]
Evidence of long-range aerosol transmission is limited, although examples are recognised by WHO.
Further research is needed to examine the spectrum of droplet size and contribution of air-mediated transmission.
SARS CoV-2 virus can survive on surfaces from a few hours to days [2]. The amount of viable virus declines over time. It may not always be present in sufficient quantities to cause infection, despite viral RNA persistence.
There is evidence of asymptomatic transmission of COVID-19 [3].
Infectious period
Latest data
PHS provides a dashboard with the latest available data including, but not limited to:
- positive cases reported
- tests carried out
- numbers of vaccinations administered
- percentage of Scotland's population who are vaccinated
General prevention measures
Non-pharmaceutical interventions help reduce transmission of COVID-19 across society.
For setting-specific advice, go to the following publications:
General advice is available in the following sections.
Physical distancing
Physical distancing is an effective measure to prevent the transmission of SARS-CoV-2 and other respiratory infections.
Physical distancing should be used where possible. This means:
- maintaining distance between people
- avoiding crowded places or large gatherings
This is achieved through:
- behaviour change – such as advising people to maintain distance
- adaptation of environments – such as screens or one-way systems
There is no legal requirement to implement physical distancing in any setting.
Health and social care settings
Guidance and advice for care homes, prisons and social, community and residential settings is available in appendix 18 of the National Infection Prevention and Control Manual (NIPCM).
Non-healthcare settings
Guidance on how measures can be maintained – such as through hybrid working – are available from the Scottish Government guidance for safer workplaces and public settings.
Face coverings or face masks
The wearing of face coverings or masks is no longer a legal requirement, however WHO recommends using face coverings or face masks in the community to reduce transmission of COVID-19.
Health and care settings
Face coverings should be worn in line with the:
as well as Scottish Government guidance on:
- extended use of face masks and face coverings in hospitals, primary care and wider community care
- use of face coverings in social care settings including adult care homes
Note that face coverings are not regarded as personal protective equipment (PPE).
Health and social care workers (HSCWs) who are exempt from wearing a face covering or mask should discuss this with their line manager and occupational health (OH) team.
Exemption from wearing a face covering or face mask should form part of any workplace risk assessment.
Non-healthcare settings
Wearing face coverings or masks is strongly recommended when:
- the risk of transmission is higher – for example, where physical distance cannot be maintained
- a risk assessment supports the wearing of them, noting exemptions
More detail can be found in Scottish Government guidance for safer workplaces and public settings.
Ventilation
Good ventilation in indoor spaces can reduce the risk of SARS-CoV-2 transmission [6].
Maximise fresh air entering a room either through:
- natural ventilation – opening windows, vents and doors, excluding fire doors
- mechanical ventilation systems – minimising the recirculation of air in rooms and throughout buildings
Health and Safety Executive (HSE) ventilation in the workplace guidance provides practical steps on improving ventilation in workplaces.
The Scottish Government provide more COVID-19 specific guidance for ventilation in workplaces.
Ventilation in healthcare settings is covered in appendix 20 of the NIPCM.
Hand, respiratory and environmental hygiene
Good personal and environmental hygiene reduces the risk of SARS-CoV-2 transmission.
Guidance on approaches to promote personal hygiene and ensure environmental hygiene is in our information and guidance for workplaces and community settings.
Healthcare settings should follow hand, respiratory and environmental hygiene advice in the National Infection Prevention and Control Manual (NIPCM).
Personal Protective Equipment (PPE)
Health and care settings
Information on PPE in health and social care is available in:
- NIPCM standard infection control precautions
- DL (2022) 10 health and social care worker access to FFP3 masks
Non-healthcare settings
The use of PPE to reduce transmission of SARS-CoV-2 or other respiratory disease in non-health and care settings should be based on an individual risk assessment. This is set out in our guidance for workplaces and community settings and in specific Scottish Government sectoral guidance.
People at highest risk
Some groups of people are at higher risk of severe illness if they catch COVID-19, even when fully vaccinated.
This includes those with a weakened immune system.
Scottish Government provides advice for people who are immunosuppressed.
Scottish Government ended the highest-risk list in Scotland on 31 May 2022.
Pregnancy
View further information on COVID-19 and pregnancy on:
Pregnant staff may also seek advice from their line manager or local OH service.
COVID-19 vaccines are recommended in pregnancy.
Addressing inequality
Age, sex, ethnicity and deprivation are inequalities that affect both risk and outcome of COVID-19 infection [7].
Older age remains the strongest risk factor for poor outcomes from COVID-19.
People from minority ethnic groups and socioeconomically deprived areas are more likely to experience harm from COVID-19.
Those living in socioeconomically deprived areas are more likely to be admitted to hospital with serious illness and have higher mortality rates.
Interventions designed to suppress viral transmission have an unequal impact across the population. This adversely affects people in more deprived populations.
Examples of this are:
- overcrowded housing preventing adequate self-isolation from others
- financial barriers to self-isolating when symptomatic
Self-isolation support grant
The self-isolation support grant remains available to help address this inequality. There is more information in the section about eligibility for SARS-CoV-2 testing.
Vaccination
The Green Book, chapter 14a (COVID-19) provides up to date information on COVID-19 vaccines, effectiveness, schedule and other relevant information.
Vaccination status, if required in public health decision making, should be defined in the following way.
- Fully vaccinated
An adult – 18 years and 4 months or older – who has had three or more doses of Medicines and Healthcare products Regulatory Agency (MHRA) approved vaccines.
This is either through completing one of the following, at least 14 days ago (where day 1 is the day of the most recent vaccination):
- 2-dose course of approved vaccine and received a booster
- 3 doses of an approved vaccine – for example, in the case of someone who is immunocompromised
This includes people vaccinated as part of a formally approved COVID-19 vaccine clinical trial.
- Unvaccinated
All other adults, including the partially vaccinated, are considered unvaccinated.
Case definitions
For the purposes of public health management case definitions have been updated to reflect changes to community testing practice.
For practical purposes these definitions may differ from current epidemiological definitions.
- Confirmed COVID-19 case
A person with detection of SARS-CoV-2 by any one of the following:
- laboratory-confirmed polymerase chain reaction (PCR) in a clinical specimen
- COVID-19 rapid diagnostic test, including point of care testing (POCT) (PCR or antigen detection tests)
- a positive lateral flow device (LFD) test
- Possible COVID-19 case
In the absence of testing, it is not possible to know if a person has COVID-19, flu or another respiratory infection based on symptoms alone.
A possible case should be considered where there are symptoms of a respiratory infection and:
- a high temperature
- the person is not well enough to go to work or carry out normal activities
Symptoms of COVID-19, flu and common respiratory infections include:
- high temperature, fever or chills
- new, continuous cough
- change in, or absence of, normal sense of smell or taste
- shortness of breath
- unexplained tiredness, lack of energy
- muscle aches or pains that are not due to exercise
- not wanting to eat or not feeling hungry
- headache that is unusual or longer lasting than usual
- sore throat, stuffy or runny nose
- diarrhoea
- feeling sick or being sick
Symptoms of COVID-19 vary in severity. Mortality is a potential outcome in those with severe disease.
Be alert to the possibility of atypical and non-specific presentations in:
- children
- older people with frailty
- those with pre-existing conditions
- those who are immunocompromised
People with epidemiological links to COVID-19 outbreaks or clusters should also be considered with a high degree of suspicion.
Testing for SARS-CoV-2
Redirect
Lateral flow device (LFD) test
LFD tests are rapid antigen tests, usually self-administered, that can be used to identify cases with a high viral load.
Positive LFD test result
A positive LFD test result indicates that someone is infected with SARS-CoV-2 and needs to be managed as a confirmed COVID-19 case.
Confirmatory PCR is not routinely required following a positive LFD test. However, someone who tested positive on an LFD may need to undertake a confirmatory PCR if:
- they need to apply for a self-isolation support grant.
- they are in the highest risk group and are eligible for new COVID-19 antivirals, monoclonal anti-body therapies and other treatments – more information can be found on NHS inform (COVID-19 treatments).
- they are taking LFD tests as part of formal research or surveillance programmes, for example, SARS-CoV-2 immunity and reinfection evaluation (SIREN).
- an HPT or another health professional asks them to, for the purposes of further investigation
In instances where a PCR result is needed, a confirmatory PCR should be taken as soon as possible and ideally within 48 hours of the LFD test.
- If the confirmatory PCR is positive, the person should continue to be treated as a confirmed case. The stay at home period should be calculated from the day of the earlier (LFD) test, even if symptoms subsequently develop.
- If the confirmatory PCR is negative and the person has no symptoms, it can be assumed there is no SARS-CoV-2 infection and no further public health action is required.
- If the person does have symptoms, but returns a negative confirmatory PCR, the person should follow guidance for individuals with respiratory symptoms as other causes of infection cannot be ruled out.
Negative LFD test result
People who receive a negative LFD result must not regard themselves as definitively free from infection as the test could be a false negative.
In addition, they may still be incubating the virus or could go on to acquire the infection in the period before their next test.
Everyone must remain vigilant to the development of COVID-19 symptoms and continue to follow existing general control measures appropriate to the setting, for example IPC measures.
False-positive LFD test results
It is rare for repeated false-positive LFD results to occur in the same individual.
When this happens during routine asymptomatic testing – for example, for work as a patient-facing HSCW – a PCR test should be recommended.
If negative, the person should be advised that repeated false-positive LFD results may continue to be obtained.
If LFD testing is essential, tests from a different manufacturer can be considered, although there is no guarantee that false-positive results will not continue to arise.
Asymptomatic testing
People who have tested positive should pause any routine asymptomatic LFD testing after the end of their isolation period.
This is for 28 days from the date of symptom onset or positive test date if asymptomatic.
Polymerase chain reaction (PCR) test
PCR is the main diagnostic test used in Scotland in NHS laboratories and UK government lighthouse laboratories.
Positive PCR test result
A positive PCR test result indicates that someone is infected with SARS-CoV-2 and needs to be managed as a confirmed COVID-19 case.
In some instances, a positive PCR result may reflect past infection (remnant viral RNA), but without a previous positive result it is not possible to know this. It may need to be managed as evidence of active infection following risk assessment.
To minimise this, people who have tested positive should pause any asymptomatic PCR testing for 90 days from the date of:
- symptom onset
- positive test date if asymptomatic
Where a test is processed
It is important to know where a PCR test is processed, for example, in a non-NHS laboratory.
You can request a list of laboratories with agreements in place with local NHS laboratories from nss.nlpq@nhs.scot
A risk assessment should be carried out for results from non-NHS laboratories that are not aligned with their local NHS laboratories or UK-accredited.
Point of care test (POCT)
A POCT – or rapid molecular diagnostic test – is performed on an individual by a health care professional and provides rapid results at, or near the point of care (or in the laboratory).
Test results are generally available in under 2 hours, often within 20 to 60 minutes.
Positive POCT test
A positive POC test result indicates that someone is infected with SARS-CoV-2 and needs to be managed as a confirmed COVID-19 case.
In some cases, rapid diagnostic tests for SARS-CoV-2 may be used to inform patient pathways.
More information is available in the COVID-19 testing requirements section of appendix 21 of the NIPCM – 'purpose of COVID-19 screening and testing' and 'testing/screening requirements in secondary care settings'.
Department of Health and Social Care's Technologies Validation Group have identified four categories for testing. This includes healthcare screening, and the minimum performance standards recommended for a test assay in each context.
Category 1 tests
Category 1 tests are PCR tests and do not require confirmation.
Category 2, 3 and 4 tests
It is good practice for all results – both positive or negative – on SARS-CoV-2 admission screens for these categories to be confirmed by PCR testing.
Samples positive by PCR have the advantage that they may be suitable for further testing by allele-specific PCR (ASP) and whole-genome sequencing (WGS). The purpose of this is for:
- clinical management
- surveillance – for example, the identification of variants and mutations (VAMs)
Eligibility for SARS-CoV-2 testing
Testing has changed from population-wide testing to reduce transmission, to targeted testing to support clinical care.
This is in line with the Scottish Government's Test and Protect transition plan.
Routine asymptomatic or symptomatic testing is recommended for the following groups.
Health and social care workers (HSCWs) and volunteers
HSCW and volunteers who work with patients and service users in a face-to-face setting should test asymptomatically and as soon as they feel unwell if they develop symptoms. This is set out under the case definitions.
This should be done by LFD twice weekly, with additional weekly PCR testing in social care.
Guidance on frequency, types of tests and related actions are set out in the DL (2022) 12 and on the Scottish Government websites for healthcare workers and social care workers.
These are subject to regular updates.
HSCWs who do not work face-to-face
HSCWs who do not work with patients and service users in a face-to-face setting should follow the advice for the general population.
This includes staff working in the emergency services and national critical infrastructure.
Face-to-face roles outlined in Annex B of DL (2022) 12
Roles considered face-to-face in social care settings are outlined in Annex B of DL (2022) 12.
These include:
- members of staff or volunteers who are regularly in a social care setting – for example, a care home or adult day care centre
- cleaners, catering, and support staff but not office-based staff members who do not enter these settings
- in the context of an individual’s own home – including sheltered or very sheltered housing – staff includes:
- those who provide care or support to the individual, such as those staff working in care at home
- personal assistants, but not, for example, maintenance staff
Highest-risk groups
People in the highest risk group who are eligible for new COVID-19 antivirals, monoclonal anti-body therapies and other treatments require a positive LFD or PCR test result to access this. There is more information on COVID-19 treatments on NHS inform.
Patients and residents in health and social care settings
People who are patients and residents of health care settings may undergo testing for appropriate management within the setting. This includes placement.
For health care settings, see appendix 21 of the NIPCM – pandemic controls for acute NHS settings including Scottish Ambulance Service (SAS)
For social care refer to the Scottish Government social care and community-based testing guidance.
Unpaid carers and visitors to health and social care settings
Unpaid carers and people visiting an adult care home should read the Scottish Government social care and community-based testing guidance.
People who are visiting a hospital should read the Scottish Government hospital visiting guidance.
Prison settings
Testing is recommended in people being admitted to prison or undergoing transfer and people resident in a prison who develop symptoms.
Other eligible groups
- People with respiratory symptoms who intend to apply for a self-isolation support grant.
- People participating in COVID-19 surveillance programmes.
- People advised to test by a health professional:
- as part of an outbreak investigation
- in relation to investigation of a COVID-19 variant and mutation (VAM).
Private testing
Private testing is available, for example, for international travel requirements.
COVID-19 remains a notifiable disease under the Public Health etc. (Scotland) Act 2008 (Notifiable Diseases and Notifiable Organisms) Amendment Regulations 2020.
Therefore, it is expected that private providers notify HPTs of all positive results, regardless of the purpose of testing.
Ordering tests
If eligible for testing, tests are available through the UK.GOV booking portal.
More information on when tests are recommended and how to access them is available:
- on NHS inform
- by phoning the national helpline on 119 – open Monday to Friday from 8am to 6pm, Saturday and Sunday from 9am to 1pm
Further testing information
More information on testing is provided in:
Testing for respiratory pathogens other than SARS-CoV-2
When necessary, HPTs should consider testing for pathogens other than SARS-CoV-2.
This would include:
- influenza A
- influenza B
- respiratory syncytial virus (RSV)
- adenovirus
This should be done in discussion with the local virologist – depending on local arrangements.
This may be particularly important if testing of SARS-CoV-2 is negative during investigation of a cluster.
Find out further information on testing on our laboratory FAQs page.
Testing for additional pathogens
Two swabs, or another respiratory sample, may be needed if testing for pathogens other than SARS-CoV-2.
You should discuss this with the local laboratory to understand if a single swab will be sufficient.
Public health management of possible cases
Individuals who are a possible COVID-19 case should follow the actions here.
NHS inform gives further advice on how possible COVID-19 cases can:
- reduce the risk of onward transmission
- protect those at higher risk of harm from COVID-19 infection
Adults
Adults (aged over 18) who meet the possible COVID-19 case definition should:
- stay at home
- avoid contact with other people until:
- they feel well
- there is no high temperature, if there was a high temperature
Children and young people
This section covers children and young people (aged 18 or under) who meet the possible COVID-19 case definition.
Mild symptoms
Children with mild symptoms can continue to attend their education setting as normal.
Mild symptoms may include having a runny nose, sore throat, or slight cough. The child should be otherwise well and not have a high temperature.
Unwell or with high temperature
Children who are unwell or have a high temperature should:
- stay at home
- avoid contact with other people, where they can, until:
- they feel well
- there is no high temperature, if there was a high temperature
There is no minimum time period for staying at home.
They can go back to school, college or childcare, and resume normal activities when they feel well and there is no high temperature (if there was a high temperature).
Health and social care workers (HSCWs)
These actions are for HSCWs and volunteers who work with patients and service users in a face-to-face setting and are possible COVID-19 cases.
Further information is available in the Directors Letter (2022) 12.
HSCWs who meet the possible COVID-19 case definition should:
- take a lateral flow device (LFD) test as soon as they feel unwell
- report the test result to their line manager
Positive LFD result
Manage as a confirmed COVID-19 case.
Negative LFD result
- Attend work if clinically well enough to do so and they do not have a high temperature.
- Continue with routine asymptomatic LFD testing at work.
If they are unwell, or have a high temperature, they should:
- stay at home
- avoid contact with other people
There is no minimal timeframe for staying at home.
On returning to work, staff should:
- resume routine asymptomatic LFD testing at work
- speak to their line manager and have a risk assessment undertaken if they meet either (or both) of the following criteria.
- They work with individuals whose immune system means that they are at higher risk of serious illness despite vaccination.
- They still display respiratory symptoms when they return to work.
Human Resources (HR) and Occupational Health (OH) may support line managers with risk assessments, as needed.
HPTs do not need to undertake individual risk assessments but may wish to have oversight of decision-making processes.
Patients and residents of health and social care settings
This section covers patients and residents of health and social care settings who meet the possible COVID-19 case definition.
Hospital settings
Refer to the NIPCM transmission-based precautions where a possible case is:
- being admitted to hospital
- currently resident in hospital
- recently discharged from hospital
Care home settings
For care home settings, refer to our:
Public health management of confirmed cases
Individuals who are a confirmed COVID-19 case should follow the actions in this section.
NHS inform gives further advice on how confirmed COVID-19 cases can:
- reduce the risk of onward transmission
- protect those at higher risk of harm from COVID-19 infection
Adults
Adults (aged over 18) who meet the confirmed COVID-19 case definition should:
- stay at home
- avoid contact with other people for a minimum of 5 days after the day they took the test, regardless of symptoms
- continue to avoid contact with other people until they no longer feel unwell and no longer have a high temperature (if they had a high temperature)
For most people, there is no requirement for further testing.
Specific groups of health and social care workers who may require further testing are described in the eligibility for SARS-CoV-2 testing section.
Children and young people
It is not recommended that children and young people test for COVID-19, unless directed to by a health professional.
Children and young people who are confirmed COVID-19 cases should:
- stay at home
- avoid contact with other people for a minimum of 3 days after the day they took the test, if possible
- continue to avoid contact with other people until they no longer feel unwell and no longer have a high temperature (if they had a high temperature)
For most children and young people there is no requirement for further testing.
A young person who works in a specific group of health and social care workers may require further testing as described in the health and social care workers section.
Health and social care workers (HSCWs)
These actions are for health and social care staff and volunteers – including those aged 18 and under – who work with patients and service users in a face-to-face setting and are a confirmed COVID-19 case.
Further information is available in the Directors Letter (2022) 12.
They should:
- stay at home
- not attend work
- avoid contact with other people for a minimum of 5 days after the day they took the test, regardless of symptoms
- continue to avoid contact with other people until they no longer feel unwell and no longer have a high temperature (if they had a high temperature)
Testing
Staff working with patients and service users in face-to-face settings can return to work when they have had two consecutive negative LFD test results.
- The first LFD test should be taken no sooner than 5 days after the day symptoms started, or the day the first positive test was taken if asymptomatic. This is described as day 0.
- Tests should be taken at least 24 hours apart.
Two negative tests
If both LFD test results are negative, staff may return to work immediately if they:
- no longer feel unwell
- no longer have a high temperature (if there was a high temperature), and have not had a high temperature for 48 hours without the use of medication
Staff must also be risk assessed if they work face to face with patients or service users whose immune system means that they are at higher risk of serious illness despite vaccination. Consideration should be given to redeployment, until 10 days after their symptoms started, or the day their first positive test was taken if asymptomatic.
All staff must continue to comply rigorously with infection control precautions and wear personal protective equipment (PPE) correctly.
Day 5 LFD test is positive
If the day 5 test is positive, staff should:
- continue to test daily, up until day 10, until there are two negative LFD test results
- take tests at least 24 hours apart
If the LFD test result is positive on day 10, they should discuss this with their line manager who may undertake a risk assessment.
Returning to work
On returning to work staff should:
- pause routine asymptomatic LFD testing for 28 days from the date of symptom onset (or first positive test date if asymptomatic)
- speak to their line manager and have a risk assessment undertaken if they:
- feel well enough to return to work but still display respiratory symptoms
- work with individuals whose immune system means that they are at higher risk of serious illness despite vaccination
Consideration should be given to redeployment until 10 days after their symptoms started (or the day their first positive test was taken if asymptomatic).
HR and OH may support line managers with risk assessments as needed. HPTs do not need to undertake individual risk assessments but should have oversight of decision-making processes.
Patients and residents of health and social care settings
This section covers patients and residents of health and social care settings who are a confirmed case.
Hospital settings
Refer to the NIPCM transmission-based precautions where a possible case is:
- being admitted to hospital
- currently resident in hospital
- recently discharged from hospital
Care home settings
For care home settings, refer to our:
Financial support for low-income COVID-19 cases to stay at home
Individuals on low income who require financial support to stay at home as advised may be eligible for the Scottish Government Self-Isolation Support Grant.
Contacts of confirmed cases of COVID-19
Routine identification or isolation of contacts of a confirmed COVID-19 case by HPTs is not recommended.
Transmission is more likely to take place as proximity and duration of contact with a case increases. Situations with higher risk of transmission include:
- within households
- where there has been an overnight stay
- where people work closely in an indoor setting
NHS inform provides further advice and actions for household and overnight contacts of both possible and confirmed cases.
Children and young people who live with someone who is a confirmed COVID-19 case should continue to attend school, college or childcare as usual.
Health and social care worker (HSCW) household or overnight contacts
These actions are for health and social care staff and volunteers – including those aged 18 and under – who work with patients and service users in a face-to-face setting and are a household or overnight contact of a confirmed COVID-19 case.
Further information is available in Directors Letter (2022)12.
Health and social care staff and volunteers should:
- continue to attend work
- continue routine asymptomatic testing at work
- continue to comply rigorously with IPC measures as set out in the NIPCM
- wear appropriate PPE for their setting
- discuss ways to minimise risk of onward transmission with their line manager, such as:
- considering redeployment to lower risk areas if they work face to face with patients or service users whose immune system means that they are at higher risk of serious illness despite vaccination
- limiting close contact with other people especially in crowded, enclosed or poorly ventilated spaces
- working from home for non-patient-facing staff
If staff develop any symptoms during these 10 days, or at any other point, they should follow the advice set out for possible cases.
Patient contacts in healthcare settings
Where a contact is currently resident or was recently discharged from a setting such as a hospital or care home, refer to the NIPCM chapter 3 – healthcare infection incidents, outbreaks and data exceedance.
Prison setting household contacts
Advice for identification and isolation of household contacts of prisoner cases is under review.
HPTs can access our guidance on prison settings.
Management of COVID-19 outbreaks by proportionate risk
COVID-19 outbreaks should be managed following principles and practices outlined in the Scottish Health Protection Network (SHPN) guidance for the management of public health incidents.
This guidance aims to provide information that health protection teams (HPTs) can use to prepare or respond to COVID-19 or outbreaks.
Setting-based management
Most setting outbreaks will be managed by settings themselves.
It is not a recommendation that HPTs should be involved in proactive identification and management of outbreaks in all settings.
The risk of spread of infection between vaccinated or otherwise healthy younger or working-age people would not usually be an indication for setting-based outbreak management by an HPT.
HPTs should be available to:
- regularly communicate and respond to those living and working in the health board area
- support setting-based preparation for, and reaction to, outbreaks
Risk-based management
HPTs have limited resources and cannot focus on all settings equally.
A risk-based approach can help identify highest priority settings. HPTs should determine priorities based on outbreak context and available resources.
HPTs should support COVID-19 outbreak self-management in lower-risk settings.
HPTs should lead COVID-19 outbreak management in higher-risk settings or situations.
Lower-risk settings or situations – supported self-management
A lower risk settings is where there is:
- relatively lower risk of direct health harms arising from infection
- a predominantly younger or working-age population
These would include the majority of:
- community-based and workplace settings
- hospitality settings, including those offering accommodation
- early learning settings, schools, and further and higher education
It is not recommended that HPTs undertake active surveillance of lower-risk settings to identify outbreaks.
Reporting COVID-19 outbreaks in lower-risk settings
There is no obligation for lower-risk settings to report to HPTs:
- clusters of confirmed COVID-19 cases
- unusually high levels of absence thought to be associated with COVID-19 – in other words, possible cases
Most of these situations will be managed by standard working practices for sickness and absence at work within each setting.
Some settings might have obligations to report clusters or outbreaks to other agencies, for example, the Care Inspectorate, environmental health departments or the HSE.
This requirement does not necessarily mean HPT notification is required or recommended.
People with higher vulnerability
There may be people with higher vulnerability within a lower-risk setting, including those who are immunocompromised.
If there is an outbreak in a setting they regularly attend, they should follow Scottish Government advice for those with higher vulnerability or any individual advice from their clinician.
HPTs should engage and support any setting to manage an outbreak, proportionate to their assessment of the risk to public health, if approached for advice.
Lower-risk settings or situations – HPT management
HPTs may consider some settings in the proposed lower-risk categories as higher risk.
HPTs may choose to manage individual-specific outbreaks in lower-risk settings as higher-risk outbreaks.
For example:
- outbreaks in lower-risk categories that have the potential to severely disrupt health services or critical infrastructure
- a persistently high or increasing staff absence due to possible or confirmed COVID-19 that is causing operational difficulties for a setting that provides a critical local role, for example, an ongoing outbreak lasting weeks
- evidence of a cluster of severe disease due to suspected or confirmed COVID-19, for example, a cluster of hospitalisations or deaths in a younger or working-age population
HPTs may make the decision to engage in the handling of any individual cases, clusters or outbreaks at their discretion.
Additional measures for these situations are set out in the higher-risk section.
National guidance for lower-risk settings
Schools
Scottish Government guidance on reducing the risks in schools
Early learning settings
Scottish Government guidance for early learning and childcare services
Community and workplaces
Scottish Government guidance on safer businesses and workplaces
All other non-healthcare settings
PHS information and guidance for workplaces and community settings
Higher-risk settings or situations – HPT management
PHS advise that higher risk settings are those where there is:
- relatively higher risk of direct health harms arising from infection
- clustering of older or clinically vulnerable people
- restricted movement or agency of elderly or vulnerable people, for example, care homes for the elderly and other vulnerable closed settings
HPTs may choose to manage outbreaks that have the potential to severely disrupt health services or critical infrastructure as a higher-risk setting.
These would include the majority of:
- care homes for the elderly or clinically vulnerable
- care at home services for the elderly or clinically vulnerable
- healthcare settings, including primary and dental care settings
- prisons
- social community and residential care (SCRC) settings including:
- adult social care building-based day services
- residential children’s homes – including settings registered as care homes
- care home services for adults (registered with the Care Inspectorate)
For SCRC settings:
- risk assessment should be undertaken in SCRC settings to provide appropriate advice
- residential SCRC settings should generally follow higher risk advice – after risk assessment, they may be considered as lower risk
- non-residential SCRC settings should generally follow lower risk advice – after risk assessment, they may be considered as higher risk
Reporting COVID-19 outbreaks in higher-risk settings
Higher-risk settings should have well-established processes for identifying outbreaks in line with setting-specific guidance.
HPTs should be informed of any outbreak identified in a higher-risk setting.
Proactive messaging from HPTs should ensure those in charge of higher-risk settings remain aware of the need to report COVID-19 outbreaks.
National guidance for higher-risk settings
Care Homes
PHS information and guidance for care home settings (for older adults)
Healthcare settings
NIPCM chapter 3 - healthcare infection incidents, outbreaks and data Exceedance
Social care and residential care
COVID-19 - information and guidance for social, community and residential care settings
Dental settings
Expert advice on outbreaks in dental settings may be available from individual board Consultants in Dental Public Health.
Other higher-risk settings outside health and social care
Outbreaks may be identified where there is no setting-specific guidance.
Initial assessment
Perform an initial assessment if the setting or situation is considered high-risk by the HPT.
- This is usually through a problem assessment group (PAG).
- Alternative local arrangements may also exist for initial assessment.
The checklist for COVID-19 outbreaks can support the assessment.
Ourbreak management plans
- Review any COVID-19 workplace risk assessment or other outbreak management plan in place.
- Work collaboratively with the setting to provide an individualised action plan for outbreak management.
Current measures and mitigations
- Based on the problem assessment, HPTs should consider measures and mitigations that are already in place when recommending actions to support outbreak management.
- Measures that need improvement should be adapted to fit with local arrangements.
- Balance all introduced measures against potential wider harms as well as benefits, in relation to control of the outbreak.
Following PAG
- Following the HPT problem assessment, management should progress to an incident management team (IMT) or be otherwise monitored as determined by the HPT.
Patient access to clinical care
Patients must be able to access clinical services as needed. Guidance on respiratory screening for all patients is available in the NIPCM standard infection control precautions.
People should contact their GP if:
- they are unwell and worried about COVID-19
- symptoms worsen after seven days
- symptoms are severe at any time
Out of hours, call:
- 111 for help and advice
- 999 for emergencies
In emergencies
If it is an emergency and an ambulance is needed, tell the 999 operator that there is a concern about COVID-19.
Scottish Ambulance Service (SAS) will triage healthcare professional calls to provide the appropriate response.
Routine appointments
Confirmed and possible COVID-19 cases should contact services to postpone routine appointments until after their infectious period of 10 days unless, the service consider attendance clinically urgent.
Essential transport of cases to home or for health care
Exposure of a potentially infectious patient to staff or other patients should be minimised during essential transport home or to healthcare settings.
Public transport
Use of public transport is not recommended.
Private vehicles
Private vehicles with an accompanying friend or family member may be used if the companion has already had significant exposure to the patient or they are aware of the possible COVID-19 diagnosis.
- The patient should sit in the rear of the car and wear a face covering or surgical face mask, if available.
- The car should be well ventilated with open windows
- All occupants of the car should ensure good hand and respiratory hygiene
Alternatives
If private transport is not available, alternative arrangements should be made locally.
- Private commercial vehicles can be used if appropriately planned and risk assessed.
- Risk assessment and travel arrangements may need to be undertaken on a case-by-case basis.
- Healthcare services should consider what local arrangements need to be put in place, supplementary to SAS and other hospital patient transport provision, to support patients to access essential health care while self-isolating.
Travel should be undertaken as safely as possible. For example, do not drive if too unwell to do so.
Further information on travelling when symptomatic can be found in our information and guidance for workplaces and community settings.
Provide clear instructions to patients for what to do and where to go when they get to the healthcare setting to minimise risk of transmission.
International travel
Travel guidance
Refer to the Scottish Government guidance for international travel for the most up-to-date advice on local and international travel.
Pre-travel guidance
Members of the public can find out the latest advice on fitfortravel.
Health professionals can access more information on TRAVAX.
Laboratory FAQs
Sensitivity
Sensitivity is the number of true positive samples detected as positive by the test.
For example, if the sensitivity value of a test is 95%, then out of 100 true positive samples, five out of 100 would incorrectly be called negative by the test.
This is also known as a false-negative result.
Specificity
Specificity is the number of true negative samples detected as negative by the test.
For example, if the specificity value of a test is 95%, then out of 100 true negative samples, five out of 100 would incorrectly be called positive by the test.
This is also known as a false-positive result.
How they are determined
Sensitivity and specificity values are determined by comparing the test to a gold standard, and assessing differences in test performance.
No laboratory test is 100% sensitive and 100% specific.
Real-time PCR (RT-PCR) testing
Currently, RT-PCR is the best available technology for detecting respiratory viruses and is the gold standard against which other tests are measured.
The analytical sensitivity of a real-time RT-PCR is not the only factor considered when testing clinical samples.
The following also need to be considered.
- The quality and timing of the clinical sample, particularly when the amount of viral material present in a patient sample will change during infection.
- The population sampled, how the sample is taken and stored, and the type of sample.
These factors are variable at different periods of time, and across different laboratories and regions of Scotland.
It is therefore not possible to give one percentage value which is representative of the sensitivity or specificity value of PCR tests in Scotland.
Reducing false-positive PCR results
A procedure was put in place in Scotland to reduce the likelihood of false-positive PCR results in NHS laboratories.
PCR is the gold standard for diagnosing many viral infections.
The technique identifies and amplifies a specific section of the viral genetic material, known as a target.
There are a variety of PCR tests currently in use in Scotland to confirm the presence of SARS CoV-2, all of which are regulated and approved by the Medicines & Healthcare products Regulatory Agency (MHRA), and thereafter validated for use by the Scottish laboratory performing the test.
Furthermore, many of the commercial assays are used as the primary method for diagnosis by several othrt countries worldwide.
All these assays have been designed to target a section of the SARS-CoV-2 genetic material which is specific to the virus.
Additional information is available in the MHRA guidance for patients, the public and professional users: a guide to COVID-19 tests and testing kits.
The Scottish NHS laboratories offering SARS-CoV-2 testing work in collaboration with the Scottish Microbiology & Virology Network (SMVN) and PHS, as well as linking in with the UK Health Security Agency (UKHSA) to ensure that all tests are suitably quality controlled, sensitive and specific.
UKHSA guidance on the minimum performance standards of SARS-CoV-2 tests can be found in the following document: Technologies Validation Group: Using tests to detect COVID-19.
PHS does not hold information on the individual validation results performed for every PCR test in use, as the validation and interpretation of the test results are carried out by the individual laboratory performing the test.
NHS laboratories and UK Government Lighthouse laboratories perform quality control procedures as part of the routine workflow. These include the use of:
- positive control material to show that the assay is working correctly
- internal control material to show that viral nucleic acid extraction is working correctly
- negative control material to show that cross contamination has not occurred
Laboratories may also take part in external quality control schemes for example Quality Control for Molecular Diagnostics (QCMD).
PHS does not hold information on the specific quality processes being used at individual laboratory level.
PCR tests are used to detect the presence of specific viral genetic material, known as a target, in a sample.
This is achieved through thermal cycling.
If the specific target is present in the sample, it is amplified in each PCR cycle.
Each manufacturer of a PCR assay will recommend a different maximum amplification cycle number, but a typical PCR assay will recommend a maximum of 40 thermal cycles.
The PCR test looks for the specific target during each cycle.
The Cycle threshold, or Ct value, is the number of PCR cycles that it takes before the virus is first detected. The Ct value may therefore be used as an indicator of the approximate amount of viral genetic material in a patient sample. In application the lower the Ct value the higher the level of virus in the sample.
There is no 'standard' Ct value. One of the roles of an NHS virology laboratory is to consider Ct values and assist in appropriate interpretation for healthcare providers. These results can be provided locally if required.
There are a number of factors involved in the interpretation of a PCR test and these are dependent on individual manufacturers and local validation.
Ct values are not directly comparable between assays and may not be reported by some PCR platforms in use. Individual laboratories will hold details of the Ct reached for each individual specimen and have quality systems in place to ensure the veracity of the results.
Serology tests detect antibodies to SARS-CoV-2 in the blood.
These are used for surveillance purposes, and defined clinical situations in NHS Scotland laboratories.
Further information on seroprevalence studies is described in the COVID-19 weekly seroprevalence for Scotland overview.
Some private laboratories and manufacturers are offering products for the diagnosis of SARS-CoV-2 infection in community settings.
We have not assessed these tests independently and therefore cannot endorse or comment further on the use of specific products in terms of their appropriateness or reliability.
Private tests should not be reported through the UK Government reporting portal.
All tests that are used in NHS laboratories are validated to ensure that they are sufficiently sensitive and specific and supporting quality control systems are in place as part of the delivery of test results.
There is the potential for harm if action is taken based on non-validated test results – they may provide false reassurance if falsely negative or a wrong diagnosis of COVID-19 if falsely positive.
Refer to our guidance for non-NHS laboratories performing SARS-CoV-2 testing within Scotland.
The Medicines and Healthcare products Regulatory Agency (MHRA) have produced comprehensive guidance on the variety of tests available for COVID-19.
All viruses continuously mutate to some extent as they spread through the population.
The impact of the mutation will differ depending on where it occurs in the genome and what component of virus that region encodes.
This can range from no change to a structural change to the virus in a key location.
When changes occur to the viral genome, this has the potential to impact a number of factors, such as:
- how well the virus can spread from person to person
- severity of the disease caused
- how susceptible someone is to infection
Viruses that contain mutations that affect the properties of the virus may be identified in a number of different ways, such as:
- routine surveillance of positive cases
- additional investigation of outbreaks or incidents in the community or hospital setting
The tests used to identify and investigate potential variants and mutations (VAMs) include:
- PCR – this test identifies samples which are positive for SARS-CoV-2
- allele-specific PCR (ASP) – this test identifies mutations associated with known variants and mutations (VAMs) so that these samples can be prioritised for additional investigation using sequencing
- whole-genome sequencing (WGS) – this looks at the entire genetic code of a virus and can be used to confirm suspected mutations from ASP, and also identify:
- additional mutations required to confirm VAM status
- new mutations
A few different mutations have occurred in the SARS-CoV-2 virus.
When mutations have the potential to affect factors such as the virulence or transmissibility of the virus, then they will be investigated further.
These may be described as a variant of concern (VOC) or a variant under investigation (VUI).
Further information on VOCs and VUIs in the UK, including case definitions for VOC and VUI, is available within UKHSA investigation of SARS-CoV-2 variants of concern: technical briefings.
In Scotland, work is ongoing to enable all suitable samples which are PCR positive for SARS-CoV-2 to be sequenced.
For technical reasons laboratories can only reliably sequence samples with relatively high viral loads – below a cycle threshold (Ct) value of 30 – hence not all positive samples are suitable to be sequenced.
Samples used for some tests, such as LFD tests, are not suitable for sequencing, so new variants cannot be identified through these testing routes.
Additional information about the Scottish genome sequencing service is available on our WGS page.
Each sample must be labelled with:
- ID
- date of birth
- type of sample
- date and time of sample
- location
Paperwork (request forms) should not be placed in the bag with the sample container.
Request form must include contact details for sharing of results.
Samples without appropriate paperwork will not be tested.
All samples should be packaged and transported in accordance with Category B transportation regulations.
UN 3373 packaging must be used for sample transport.
If required, transport requirements should be discussed with the local laboratory.
Further information on safe handling can be found in the UKHSA guidance for safe handling and processing for laboratories.
Health board | Laboratory contact details |
---|---|
Ayrshire and Arran | 01563 827 420 |
Borders | 01896 826 250 or 01896 826 258 |
Dumfries and Galloway | 01387 241 560 |
Fife | 01592 648 169 |
Forth Valley | 01324 566 692 |
Golden Jubilee | 0141 951 5931 |
Grampian | 01224 552 444 |
Greater Glasgow and Clyde | 0141 201 8721 for virology 0141 211 4000 for out of hours – ask for on call virologist west.ssvc2@nhs.scot |
Highland | 01463 704 206 or 01463 704 207 |
Lanarkshire (Wishaw) | 01698 366 405 |
Lothian | 0131 536 3373 (option 2) for virology 0131 536 1000 for out of hours – ask for on-call virologist virologyadvice@nhslothian.scot.nhs.uk |
Orkney | 01856 888 217 |
Shetland | 015950 743 011 |
Tayside | 01382 632 559 |
Western Isles | 01851 708 033 |
Checklist for COVID-19 outbreaks
The HPT should undertake an initial risk assessment following notification of an outbreak.
If possible, this should be done in collaboration with the setting owner or manager.
The HPT should develop a standardised approach to risk assessment.
The tools here can help with this.
Assess if anyone in the setting was:
- admitted to hospital
- admitted to an intensive care unit (ICU)
- known to have died as a result of COVID-19 during this incident
Assess if the setting population is particularly vulnerable, for instance if they are:
- unvaccinated adults
- elderly people
- immunocompromised people
Collate and review case and contact data using HPZone.
Produce a basic line-list summarising:
- current known cases
- contacts
- onset dates
- symptomatic or asymptomatic cases
Assess initial links between cases and the suspected attack rate within the setting.
Assess the potential for:
- extensive spread
- number of contacts or case
- closeness of contacts in the setting, for example, shared sleeping accommodation
Reflect on the strength of collaboration:
- Is the setting experienced and engaged with the management of incidents such as this?
Assess the potential for those in the setting to spread infection to other settings, including higher-risk settings, for example, medical students.
Assess the following:
- actions taken to date
- number of cases and contacts self-isolating or undertaking testing
- compliance
- infection control measures
- handwashing
- current physical distancing measures in place
- setting layout
Consider likely adherence to any potential additional measures.
Consider:
- any communications already issued
- any operational issues due to staffing anxieties or absence
- anxiety or misinformation circulating in staff or others in setting
- social media context
- press interest
- ages and cohorts affected
Is a PAG or IMT required?
After the risk assessment, consider the need for a PAG or IMT meeting.
This should be done in line with the management of public health incidents: guidance on the roles and responsibilities of NHS-led incident management teams.
Work in partnership
The HPT should work with key stakeholders – including the setting owner – to make recommendations on ongoing assessment and control of the incident.
This could be through an IMT or other approach.
If relevant, invite:
- environmental health officers
- HSE
- Food Standards Scotland
For significant incidents, invite observers:
- Public Health Scotland
- Scottish Government
Use the following checklist for further investigation and control.
Maintain and update the line list.
Consider the operational implications of the incident for the setting.
Links between cases
Consider:
- hypothesis of transmission
- layout of setting and establish linkages between cases, both in setting and outside the setting, for example, social events
Testing
When a COVID-19 case occurs in a higher-risk setting, a lateral flow device (LFD) or polymerase chain reaction (PCR) test – or a combination – can be used to support an initial risk assessment.
Repeated rounds of mass testing are unlikely to be justifiable for outbreak management purposes.
Vaccination coverage
Assess coverage and consider approaches to maximise vaccination uptake in response to the incident.
The Green Book advises not to use vaccination as a tool in managing outbreaks.
The risks and benefits of a vaccination session during an outbreak must be carefully considered, in particular the ability to vaccinate while maintaining IPC measures.
The lack of an established evidence base on this means that the local HPT should undertake a risk assessment to determine the appropriate next steps in such situations.
Review implementation of appropriate PHS guidance for the setting.
Cohorting of population or minimising contact between groups ('bubbling').
Physical distancing – policy or guidance and adherence.
Include discussion of:
- car sharing
- communal areas
- changing rooms
- breaks, including smoking
Reminder to population of importance of symptom vigilance and following NHS inform advice.
PPE and face coverings
- availability
- quality
- compliance
Personal hygiene
- hand hygiene
- respiratory hygiene
Environmental cleaning
Ventilation
Consider wellbeing and the impact of incident and any enhanced mitigations on those involved in or using the setting.
This includes the financial impact on cases and contacts.
Consider support required.
Inform other stakeholders and widening participation as required.
Assess the need for a proactive or reactive media statement.
The HPT should chair the problem assessment group (PAG) or incident management team (IMT).
Housekeeping
- Ask for consent for supportive recording, if useful for minute-taking.
- If there are new attendees, explain PAG/IMT process briefly, including acronyms.
- Reminder about confidentiality regarding reporting back organisationally generally and for personal identifiable information.
- Reminder about possible freedom of information (FOI) enquiry for documentation and other communication.
- Declarations of potential conflicts of interest - for example, private owners, service managers or people otherwise connected to the situation. This could be a link to specific school, business or service.
Review
- membership of the group
- case definition
Update
If the company or setting manager is invited to provide an update or support risk assessment, this should be to only part of the PAG or IMT to enable members to discuss final conclusions.
Next meeting
- Establish plans for next meeting.
Conclude the outbreak investigation when there have been:
- no new cases for a minimum of 14 days from the last potential exposure to a confirmed case
- no further follow-up actions are required to mitigate the potential for future outbreaks
Related resources
This guidance should be read with reference to these related resources.
Our guidance
COVID-19 guidance for specific settings, in particular for:
Scottish Health Protection Network (SHPN) guidance
Guidance on the management of public health incidents.
Infection prevention and control (IPC) guidance
Antimicrobial Resistance and Healthcare Associated Infection Scotland (ARHAI) guidance found in the National Infection Prevention and Control Manual (NIPCM).
Scottish Government guidance
Clinical guidance
The Scottish Intercollegiate Guidelines Network (SIGN) produces clinical guidance on COVID-19.
Information for the public
NHS Inform provides information for the public, including translated materials.
Abbreviations
- ARHAI
Antimicrobial Resistance and Healthcare Associated Infection Scotland
- COVID-19
coronavirus disease 19
- Ct
cycle threshold
- GDG
guidance development group
- FFP
filtering face piece
- HPT
health protection team
- HSCW
health and social care worker
- HSE
Health and Safety Executive
- IMT
incident management team
- IPC
infection prevention and control
- LFD
lateral flow device
- MHRA
Medicines and Healthcare Products Regulatory Agency
- NIPCM
National Infection Prevention and Control Manual
- OC
occupational health
- PAG
problem assessment group
- PCR
polymerase chain reaction
- PHS
Public Health Scotland
- POCT
point of care testing
- PPE
personal protective equipment
- RNA
ribonucleic acid
- RSV
respiratory syncytial virus
- SARS-CoV-2
severe acute respiratory syndrome coronavirus 2
- SHPIR
Scottish Health Protection Information Resource
- SIGN
Scottish Intercollegiate Guidelines Network
- SIREN
SARS-CoV-2 immunity and reinfection evaluation
- UKHSA
UK Health Security Agency (formerly Public Health England)
- VAMs
variants and mutations
- VOC
variants of concern
- VUI
variants under investigation
References
-
Rapid review of the literature: Assessing the infection prevention and control measures for the prevention and management of COVID-19 in health and care settings. Antimicrobial Resistance and Healthcare Associated Infection Scotland. V20, 04.11.21.
-
Science Brief: SARS-CoV-2 and Surface (Fomite) Transmission for Indoor Community Environments [Internet]. [cited 2021 Nov 05].
-
Buitrago-Garcia D, Egli-Gany D, Counotte MJ. Occurrence and transmission potential of asymptomatic and presymptomatic SARS-CoV-2 infections: a living systematic review and meta-analysis. PLoS Med. 2020;17
-
Questions and answers on COVID-19: Basic facts [Internet]. [cited 2021 Nov 05].
-
COVID-19 disease [Internet]. [cited 2021 Nov 05].
-
Heating, ventilation and air-conditioning systems in the context of COVID-19: first update [Internet]. [cited 2021 Jul 21]
-
Katikireddi SV, Lal S, Carrol ED, Niedzwiedz CL, Khunti K, Dundas R, Diderichsen F, Barr B. Unequal impact of the COVID-19 crisis on minority ethnic groups: a framework for understanding and addressing inequalities. J Epidemiol Community Health. 2021 Oct;75(10):970-974.
Submit feedback on this guidance
Health protection teams (HPTs) and other stakeholders have contributed to the development of this guidance through regular feedback and comments.
As this format is a new approach to delivering this guidance, we welcome feedback from health protection teams on this guidance and how we can improve it.
If HPTs have a specific query about the application of the guidance please email PHS Enquiries and Guidance Cell or call PHS on call for any urgent queries.