Guidance for the public health management of COVID-19 infections in the community and community settings
Guidance for health protection teams (HPTs)

Purpose and scope

This guidance is primarily for healthcare professionals working in health protection teams (HPTs) and healthcare settings across Scotland.

It may also be relevant for people working in or using related services.

It aims to provide a clear, concise, and accessible overview of the public health measures that should be taken to prevent and manage COVID-19 infections in the community, for example:

• at home
• in schools
• in work places
• in prison settings

Please also read the PHS guidance for the public health management of COVID-19 infections in social and residential care settings.

Using this guidance

The guidance supports, but does not replace:

• individual expert public health or 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

It supports a human rights-based approach, concordant with The Human Rights Act 1998.

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 guidance should be read with reference to these related resources.

Health protection team contacts

Health protection teams in each health board area are the primary team supporting the control of outbreaks in community settings.

Local services have access to their local HPT for such operational advice.

Public Health Scotland, at national level, does not provide this directly.

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.

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 11 March 2020.

On 5 May 2023, WHO declared an "end to COVID-19 as a global health emergency".

Course of the disease

COVID-19 presents with a range of symptoms with varying severity.

It is estimated around one in three people with COVID-19 do not display symptoms.

Most people recover quickly, usually starting to feel better in a few days. Some people take longer, and symptoms can affect the whole body.

The severity of illness with successive strains has differed, with decreasing case fatality rates and risk of hospitalisations observed over time. This is due to a combination of a reduction in harmful intrinsic characteristics of the virus, and other factors such as natural immunity, vaccination, and the availability and use of therapeutics.

The risk of severe COVID-19 disease is influenced by factors such as age, obesity, ethnicity, socio-economic status, natural and vaccine-induced immunity and the SARS-CoV-2 variant causing infection.

There is evidence to suggest that individuals who have suffered from either mild or severe COVID-19 can experience prolonged symptoms or develop long-term effects, such as long COVID.

Clinical presentation

The main symptoms of COVID-19 are:

• high temperature, fever or chills
• new and continuous cough
• change in, or absence of, normal sense of smell (anosmia) or taste (ageusia)

Other symptoms can be:

• 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.

It is important to be alert to the possibility of atypical and non-specific presentations in:

• children and older people
• those with pre-existing conditions
• those who are immunocompromised

Transmission

SARS-CoV-2 is spread by respiratory particles. This occurs mainly through close contact with infectious individuals.

Transmission risk increases when:

• people are close to each other (usually within 2 metres) or there is overcrowding
• people display symptoms
• in poorly ventilated indoor environments
• in environments where infection control training practices are inadequate, including for cleaning processes

Indirect transmission can occur through contact with contaminated surfaces.

The relative risk is likely to be lower than other routes of exposure, however this route may still be important in higher risk settings.

The transmission risk for any respiratory illness, including COVID-19, increases with length of exposure and proximity to the infected individual.

Infectious and incubation periods

Studies show that the highest risk of transmission occurs a few days before and within the first five days after symptom onset, but can be up to 10 days after symptom onset.

The incubation period for SARS-CoV-2 varies according to the circulating variant.

However, the average incubation period is between three and six days, with a range from 1 to 14 days.

Epidemiology

Public Health Scotland provides a dashboard on viral respiratory diseases in Scotland to support the understanding of transmission of infection.

This includes, but is not limited to:

• estimated COVID-19 infection levels and number of reported positive COVID-19 cases
• acute COVID-19 admissions to hospital and hospital occupancy

Intensive care unit (ICU) admissions and bed occupancy are published in the monthly PHS viral respiratory diseases (including influenza and COVID-19) in Scotland surveillance report.

COVID-19 vaccination uptake data is available on the PHS vaccination surveillance dashboard.  

General prevention measures

Prevention advice

General prevention advice is recommended to:

• help reduce the spread of COVID-19 and other respiratory infections
• protect those at highest risk

This includes the following.

Vaccination

Adhering to the recommended vaccination schedule (see NHS inform on COVID-19 vaccination).

More information is available in the vaccination section of this guidance.

Hygiene measures

Ensuring effective hand hygiene, respiratory and cough hygiene and safe management of the environment (see UKHSA living safely with respiratory infections, including COVID-19).

Respiratory hygiene

• Covering mouth and nose with disposable tissues reduces onward transmission of viruses and bacteria when coughing or sneezing.
• Tissues should be placed in a bin immediately and hands washed.
• Coughing or sneezing into the crook of the elbow is advised, and not into hands when tissues are not available.

Hand hygiene

• Washing hands removes viruses and other micro-organisms, making infection less likely when people touch their faces.
• Using soap and water is the most effective way to clean hands, especially if they are visibly dirty. This should be done regularly throughout the day, especially before meals and after toileting.
• Hand sanitiser can be used when soap and water are not available.

Safe management of the environment

• Clean surfaces should be maintained at home and workplaces.
• Particular attention should be paid to surfaces that are touched frequently, such as handles, light switches, work surfaces and electronic devices, for example, remote controls or phones.

Avoiding contact

Staying at home and avoiding contact with other people when respiratory symptoms are present is advised, especially with high fever or feeling unwell (not well enough to carry out normal duties or activities):

• Keeping away from vulnerable others (older people, those with general poor health, the immune-compromised) when respiratory symptoms are present is sensible and advised. Visits to hospitals and care homes are not advised.

• Returning to normal activities – for example, work, school, routine social events – is reasonable when fever has subsided without antipyretics and the individual feels well. There is no specific time limit for avoiding contact with others, although 48 hours can be used and is discretionary.

• Self-isolation is also advised for people with respiratory symptoms who reside in closed settings such as community or educational residential dwellings and prisons.

Ventilation

Allowing fresh air into indoor environments, especially if someone with COVID-19 or another respiratory infection is present.

This can be done by:

• • by opening a door or window even for a few minutes at a time, periodically, maintaining comfortable temperature levels
  • using trickle vents and grills, for a constant small flow of air

  • by reviewing ventilation in the workplace guidance from Health and Safety Executive (HSE)

More information

Further advice on prevention is available from NHS inform.

SARS-CoV-2 testing and contact tracing are no longer recommended for general population management of COVID-19 disease, except in very selective circumstances, under the direction of the local health prrotection team.

International travel has largely re-opened, but disruption to travel remains a risk. Countries can lift or implement travel restrictions and entry requirements to curtail the spread of COVID-19 and its variants at short notice. For additional information, see Travax: COVID-19 health considerations to travel.

Health and social care settings

Health and social care settings are advised to adopt and implement the infection prevention and control (IPC) guidance for standard infection control precautions and transmission-based precautions.

These are available in the National Infection Prevention and Control Manual (NIPCM):

• Chapter 1 - standard infection control precautions
• Chapter 2 - transmission-based precautions

Care homes settings

Care Home settings are advised to adopt and implement infection prevention and control (IPC) guidance for standard infection control precautions and transmission based precautions.

These are available in the Care Home Infection Prevention and Control Manual (CHIPCM).

For setting specific care home guidance for COVID-19, see PHS guidance for the public health management of COVID-19 infections in social and residential care settings.

Prison settings

This guidance recognises that prisons are living areas for the Scottish prison population, with healthcare services operating within them.

Infection prevention and control guidance differs for these two areas within prisons.

Living areas in prisons are advised to follow general prevention measures.

Healthcare services within prisons should refer to the PHS guidance for the public health management of COVID-19 infections in social and residential care settings.

Workplace and community settings risk assessment

Risk assessments help to identify the most effective mitigation measures to be followed by organisations, their employees and service users, considering the circumstances present.

See Scottish Government information on safer workplaces and public settings.

People at highest risk

Some groups of people are at higher risk of severe illness when exposed to COVID-19.

This includes:

• older people
• pregnant women
• people with certain chronic diseases
• those with a weakened immune system

Advice from the UK Joint Committee for Vaccination and Immunisation for individuals with immunosuppression due to disease or treatment is available in The Green Book, chapter 14a (COVID-19).

People in the highest risk group who are eligible for COVID-19 antivirals, monoclonal anti-body therapies and other treatments require a positive LFD test result to access these.

There is more information on eligibility and how to access COVID-19 treatments on NHS inform.

Pregnancy

Pregnant women appear no more or less likely to contract SARS-CoV-2 than the general population. It is estimated around one in three people with COVID-19 do not display symptoms.

There is evidence that pregnant women may be at increased risk of severe illness from COVID-19 compared with non-pregnant women, particularly in the third trimester.

COVID-19 vaccination has a significant protective effect in pregnancy (see the vaccination section).

For more information visit the Royal College of Obstetricians & Gynaecologists (RCOG).

Vaccination

COVID-19 vaccines are effective at building immunity against coronavirus in most people.

Some people may still develop coronavirus infection despite vaccination. However, a vaccine reduces the risk of suffering from severe illness or death.

The Joint Committee for Vaccines and Immunisation (JCVI) advises UK health departments on immunisations for the prevention of infections and/or disease following due consideration of the evidence on the burden of disease, and on vaccine safety and efficacy.

Individuals eligible for COVID-19 vaccine will be contacted by the NHS as per JCVI recommendations. The Green Book, chapter 14a (COVID-19) provides up to date information on COVID-19 vaccines, effectiveness, schedule, and other relevant information.

NHSScotland recommends the 2024 spring COVID-10 vaccine for those:

• aged 75 years and over on 30 June 2024 (those born on or before 30 June 1949)
• living in a care home for older adults
• aged six months or over (by or on 31 March 2024) and have a weakened immune system

Some people can be at higher risk of severe illness if they are exposed to COVID-19, even when fully vaccinated. However, if infected, the severity of illness is reduced in those who are vaccinated, even in this group.

Further details and advice for people at highest risk are available on NHS inform and the Scottish Government website.

Pregnancy

It is particularly important for pregnant women to have a full course of COVID-19 vaccines – if they have not already done so – to protect themselves and their babies.

Being fully vaccinated with two doses and a booster makes it less likely to be admitted to hospital with COVID-19 than those who are unvaccinated.

View further information on COVID-19 and pregnancy on:

• Ready Steady Baby
• Royal College of Obstetricians & Gynaecologists (RCOG)

Pregnant staff may also seek advice from their:

• local midwife
• line manager
• local occupational health service

Access to clinical care

Most people affected by acute respiratory infection – in particular SARS-CoV-2 – can be managed at home with rest, hydration and simple anti-pyretic medication.

People should contact their GP if:

• they are unwell and worried about COVID-19 infection
• symptoms worsen after seven days
• symptoms are severe at any time
• if their cough lasts for more than three weeks

Out of hours, call:

• 111 for help and advice
• 999 for emergencies

If it is an emergency and an ambulance is needed, the 999 operator needs to be advised that the patient has respiratory symptoms, or if there is a specific concern about COVID-19.

Access to urgent healthcare services should not be delayed for individuals whether a respiratory infection is suspected or not.

An admission screening respiratory symptom assessment aide is available and further information on IPC measures can be found in the NIPCM.

Testing for SARS-CoV-2

It is considered appropriate to manage COVID-19 like other respiratory illnesses.

This is currently indicated due to the:

• ongoing success of the vaccination programme
• high levels of immunity presently reached among the general population
• reduced severity of illness and frequency of hospitalisations
• increased access to treatments

The general population is no longer advised to seek SARS-CoV-2 testing before taking action to stay at home.

Free covid tests are no longer available to the general public since presumed COVID-19 can now be generally managed, based on symptoms.

Eligibility for SARS-CoV-2 testing

Testing for COVID-19 is currently indicated to:

• support clinical diagnosis, when advised by a healthcare professional
• test those who are symptomatic and at higher risk, if they are eligible for COVID-19 treatments
• support outbreak management, on advice from local HPTs or local infection prevention and control teams
• support respiratory infection surveillance through sentinel general practices (CARI programme)

The routine testing of asymptomatic COVID-19 residents of care homes and hospices upon discharge from hospital ceases from 3 June 2024.

A risk assessment approach should be taken prior to transfers out of hospital. The ARHAI respiratory screening questions can be used to support risk assessment carried out by the hospital team in preparation for discharge, in collaboration with the receiving setting.

Find out more information in the Scottish Government CMO(2024)06 letter.

The routine COVID-19 testing of symptomatic health and social care staff is no longer required, in line with the Scottish Government CMO(2023)12 letter.

Health and social care staff should adhere to general advice, also available on NHS inform on managing symptoms of a respiratory infection and stay at home until fever has subsided and they feel well.

Polymerase chain reaction (PCR) test

PCR is the main diagnostic test for SARS-CoV-2 and is used in Scotland in NHS laboratories.

A positive PCR test result indicates that an individual is highly likely to be infected with SARS-CoV-2.

In some instances, a positive PCR result may reflect recent past infection (remnant viral RNA), that is no longer infectious, 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. It is also important to be aware that the likelihood of a false positive result increases when SARS-CoV-2 population prevalence is low.

A negative PCR COVID-19 result does not rule out other infectious respiratory pathogens, such as influenza and respiratory syncytial virus (RSV).

False negative PCRs are also possible if a person is still incubating the infection.

Where a test is processed

Occasionally, a query may arise where a PCR test has been performed in a non-NHS (or private) laboratory.

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.

Whole genome sequencing

PCR positive samples may be suitable for further characterisation by whole-genome sequencing (WGS).

The purpose of this is for viral surveillance – for example, the identification of variants and mutations. All PCR positive samples should be considered for whole genome sequencing (WGS), by laboratories, taking Ct value into consideration where necessary.

Community Acute Respiratory Infection (CARI) Surveillance

CARI is PHS’s sentinel respiratory surveillance system that aims to monitor the burden and impact of acute respiratory infection in the community.

Approximately 180 GP practices participate across Scotland as sentinel sites. Patients from these practices who present with symptoms of acute respiratory infection (ARI) and who fit the CARI case definition are tested for 10 respiratory pathogens:

• influenza A and B
• SARS-CoV-2
• RSV
• rhinovirus
• seasonal coronavirus
• human metapneumovirus
• parainfluenza
• adenovirus
• Mycoplasma pneumoniae

Test results are collated and analysed by PHS and individual test results are reported back to GP practices.

Data from the CARI surveillance programme is available in the PHS weekly report on respiratory infection and the PHS respiratory dashboard.

If practices are interested in joining this initiative, please contact phs.cari@phs.scot 

Lateral flow device (LFD) test

Carrying out an LFD, a rapid antigen test, when experiencing respiratory symptoms is no longer required nor recommended for most people.

Individuals should now follow NHS inform advice when symptomatic.

LFDs are still available for people in the highest risk group who are eligible for COVID-19 antivirals.

Find out more information on COVID-19 treatments on NHS inform.

Expired LFD kits should not be used as the results are not reliable, whether they are positive or negative.

Further technical testing information

More information on testing is provided in the Medicines and Healthcare products Regulatory Agency (MHRA) guidance on the variety of tests available for COVID-19.

Testing for respiratory pathogens other than SARS-CoV-2 as part of an investigation of a cluster

When a cluster of individuals with respiratory symptoms presents and there is clinical concern, HPTs should consider advising testing for pathogens other than SARS-CoV-2, in line with local arrangements.

Since there is no longer a central process for settings such as care homes or prisons to obtain PCR kits, HPTs should confirm the local testing pathway for investigation of community outbreaks, as this can vary across health boards.

This may include:

• influenza A
• influenza B
• respiratory syncytial virus (RSV)
• adenovirus
• bacterial organisms

This particularly applies to closed settings – for example care homes or prisons – and in at-risk populations if testing for SARS-CoV-2 is negative during investigation of a cluster and the organism remains unidentified.

Variants and mutations (VAMs)

Should a SARS-CoV-2 variant or generic mutation of (VAM) present a worrying signal indicative of unexpected worse outcomes, an epidemiological investigation can be stood up to support rapid risk assessment of a developing incident.

The VAM Plan is a co-ordinated effort led by PHS in collaboration with NSS, laboratories and local HPTs.

It describes a process for PCR kit distribution and sampling, testing and reporting on respiratory specimens, through rapid contact tracing.

Read the plans for SARS-CoV-2 variant assessment and response (currently being updated).

PCR and WGS results are then linked to epidemiological information, obtained through patient interview, all in the absence of a full population-level testing programme. The pathways for kit distribution (postal or courier) to appropriate locations and data flow are outlined in the plan.

This investigation will support assessment, escalation and management of an incident suspected to be stemming from the introduction of a new VAM of public health importance

The management of such incidents will follow the principles and processes outlined in the management of public health incidents guidance.

Public health management of COVID-19 cases

Public Health management of COVID-19 cases is now based on respiratory symptoms as testing is no longer available to the majority of the population (see eligibility criteria section).

Individuals who are symptomatic or a confirmed COVID-19 case should follow the actions in this section to:

• reduce the risk of onward transmission
• protect those at higher risk of harm from COVID-19 infection

NHS inform gives further advice to support confirmed COVID-19 cases or people with respiratory symptoms.

Adults and children – including health and social care workers (HSCW) – who meet the confirmed COVID-19 case definition or have respiratory symptoms should:

• assess the need to stay at home
• avoid contact with those at higher risk of infection
• continue to avoid contact with other people until they no longer feel unwell nor have a high temperature. A 48-hour timeframe from the end of a period of high fever (without use of antipyretics) can be used to support decision-making, but is discretionary

There is no need to test to end isolation.

Returning to work

People can return to school and work once the fever and feeling of unwellness have subsided.

Particular regard is needed for health and social care settings where staff returning to work in specific areas of higher clinical risk, need to agree this with their line manager, using a risk assessment approach.

For example, staff working with severely immune-compromised individuals, may be asked to undertake non-clinical work initially.

Removal of temporary COVID-19 special leave for health and social care workers (HSCW)

To assist staff and NHS through the COVID-19 pandemic, a series of temporary policies and variations to standard terms and conditions were put in place.

In light of the revision to national COVID-19 testing on August 2023 (CMO(2023)12), this special leave provision (DL(2022)21) has been reviewed and is now replaced by DL(2024)03.

From 1 April 2024, healthcare managers are expected to manage staff sick leave in relation to COVID-19 the same way as other respiratory infection.

Management of COVID-19 outbreaks

COVID-19 outbreaks should be managed following principles and practices outlined in the management of public health incidents guidance, underpinned by the Public Health etc (Scotland) Act 2008.

An outbreak is defined as an incident involving two or more linked infectious cases over a defined period of time and place. For COVID-19, the period of time of assessment of linked cases is up to 14 days.

Case definition

For the purposes of public health management, case definitions can be adapted to reflect community testing practice at the time.

 

The case definition may differ from the epidemiological definition in the context of an outbreak investigation, for example, a presumed positive case may based on symptoms and epidemiological link to another case.

Declaring an outbreak

Declaration of an outbreak is made by the local HPT and managed:

• directly under the authority of the relevant health board 'competent person' (or nominated deputy), underpinned by the Public Health etc (Scotland) Act
  or
• through the constitution of an incident management team, chaired by a health board Competent Person (or nominated deputy), when indicated.

In both instances, a public health risk assessment approach should be undertaken to:

• interrupt or minimise ongoing transmission and other deriving harms
• balance the rights of individuals versus the safeguarding of the community in which they live, reside or work.

This should be done:

• in partnership with relevant stakeholders
• with regular reviews of the circumstances of the outbreak
• with advice provided on control measures to be implemented
• with clear communication to those affected

Once five days have lapsed since symptom onset of the latest case, the HPT can risk assess which control measures can be discontinued while staff maintain vigilance for any new suspected cases, until the outbreak is declared over.

Clusters of COVID-19 cases in the community are no longer routinely formally managed as outbreaks in most settings.

Outbreaks in closed settings can occur and will be managed by local HPTs as per the relevant guidance, with professional judgment.

Declaring the end of an outbreak

The outbreak can be declared over by the health board Competent Person when:

• there have been no new cases for a minimum of 14 days from the last potential exposure to a COVID-19 case
  and
• the local HPT considers that:
  • existing cases have been isolated or cohorted effectively
    and
  • guidance on IPC and other interventions is being applied appropriately (see general prevention measures)

Prison settings

Symptomatic or positive COVID-19 test

Similar to the general population, prison residents with symptoms suggestive of COVID-19 do not require testing – unless clinically indicated or if they have a health condition which makes them eligible for coronavirus treatments.

However, they are advised to isolate separately from their household cohort, in a single cell, in order to prevent ongoing transmission to other residents.

Residents can end self-isolation when they:

• have been without fever for 48 hrs without use of medication (such as paracetamol)
  and
• feel well enough to resume normal activities

If cells with en-suite facilities are not available for self-isolation, then access to hot water and showers must be ensured for personal hygiene.

Those in isolation must continue to have access to meals and health and care including prescribed medication – these may need to be brought to the cell.

Staff should maintain symptom vigilance during the self-isolation period. This includes for signs of deterioration or mental health problems.

Access to outdoor exercise should continue, providing the resident feels well enough. The frequency and duration of exercise is determined by an individual risk assessment and distance from others should be adequately maintained.

Residents may need to go to hospital during their self-isolation period.

Staff must inform the ambulance service and ward staff in advance that the individual has respiratory symptoms (or confirmed COVID-19 if that is the case) and of the need for self-isolation on arrival.

Escorting staff must follow hospital IPC procedures and wear PPE in line with the NIPCM, when escorting on hospital premises.

Moving between settings

Liberations

The local HPT can support the prison healthcare team with this process in conjunction with SPS and local authorities, should liberation arise when the individual has respiratory symptoms.

Visiting

General prevention measures should be followed for visiting.

Prison management should aim to operationalise these measures with the prison healthcare team and the local HPT, when indicated.

Visitors are advised not to attend with respiratory symptoms and follow general population advice to stay at home according to NHS inform.

Outbreak management

COVID-19 outbreak management in prisons should follow existing, well-established public health principles and practice guided by the local health protection team.

The HPT has autonomy to deviate from the guidance according to local circumstances and risk assessment.

Prisons are considered higher-risk settings for outbreak management purposes.

This is due to:

• the size of prison estates and their large resident and staff populations
• opportunities for infections to spread quickly throughout the facility due to the communal nature of the setting
• the higher proportion of residents originating from more deprived socioeconomic backgrounds, as a risk factor for poorer health
• variable levels of vaccination coverage across the prison population.

Related resources

This guidance should be read with reference to these related resources.

Our guidance

• PHS information and guidance for social and residential care settings

NHS inform

• Information for the public

Infection prevention and control (IPC) guidance

Antimicrobial Resistance and Healthcare Associated Infection Scotland (ARHAI) guidance is available in the:

• National Infection Prevention and Control Manual (NIPCM).
• Care Home Infection Prevention and Control Manual (CH IPCM)

Scottish Government and Scottish Health Protection Network (SHPN) guidance

• Guidance on the management of public health incidents

Scottish Government guidance

• COVID-19 guidance

The Scottish Intercollegiate Guidelines Network (SIGN)

The Scottish Intercollegiate Guidelines Network (SIGN) produces:

• various clinical guidance on COVID-19
• long COVID patients publications
• managing the long-term effects of COVID-19 (SIGN, NICE and RCGP)

Local NHS laboratory contact details

Abbreviations