Data about the outbreak, including about testing, positive cases and contacts, is essential for good local outbreak control. Managing data is a complex task, with many different sources and streams, with varying levels of timeliness and accuracy.
There are also particular issues, arising from limited data flows still coming to local authorities.
In order to use data effectively and make sense of a wealth of statistics, we have adopted a “function-led” approach in B&NES in which all information will be seen through the context of these three fundamental questions:
- How do we monitor the general level of the outbreak in B&NES and further afield?
- How do we assure that the Test and Trace system is working well locally?
- How do we identify localised outbreaks as early as possible?
There are four recommended metrics that should be used to track the local general level of outbreak/infection in Bath and North East Somerset:
- Individuals reporting symptoms - by daily tracking using data from the 111 telephone service/GPs Primary Care of B&NES residents/registered (possibly from the further development of the COVID-19 Capacity Threshold and Triggers Report, 1.2).
- Positive swab test results - by daily tracking of positive Pillar 1 and Pillar 2 test results, provided by PHE (via. HPZone) (from the daily MSOA and weekly postcode-level Case Line Lists, 5.1 and 5.3 respectively).
- Admissions to hospital - by monitoring daily suspected, and later tested positive, or already known to be positive, in-patients (ie: community acquired infection), as well as newly COVID-19 positive in-patients acquired in the RUH (ie: nosocomial, or hospital acquired, infections)(possibly from the developing COVID-19 Capacity Threshold and Triggers Report, 1.2).
- Deaths – by tracking, preferably from the weekly internally supplied registered deaths (2.5), or alternatively weekly ONS death registrations releases (2.3).
All of these metrics are tracked on a daily basis, either by the BI Team through dashboards, or by BSW CCG through daily Sitreps.
In addition, a number of different alert systems are produced (1.1,1.2 and 1.3), particularly the PHE South West Early Warning for Confirmed COVID-19 Cases (1.3), are logged and tracked by the B&NES Business Intelligence team, but some occur after the release of daily positive test data (5.1).
We should aim to understand the following metrics:
- Whether everyone who needs a test gets a test.
- Whether tests are turned around in an appropriate timescale, for example: timely delivery and return of tests for home testing kits, as well as timely notification of results.
- Whether people with appropriate positive test results are contacted quickly, their close contacts are identified, tracked and traced in a timely manner; and everyone who should be self-isolating is actually doing so for the recommended period.
At present, local intelligence has been provided with information regarding the following:
- Testing in care homes - suspected cases recorded (B&NES Care Home Sitrep, 3.2) and tests completed (PHE Line Lists, 5.1 and 5.3).
- Summary contact tracing statistics from Department of Health & Social Care (DHSC), including all of the following:
- how many confirmed cases have been referred
- how many contacts have been identified, and how many contacts have been completed
- how many have been managed by Level 1 Health Protection Teams
These data sets and statistical returns are reviewed on publication by the Business Intelligence team, and by Adult Social Care, Adult Safeguarding and Public Health teams, in the case of Care Home Sitreps.
The issue of publishing statistics to show how effectively the testing programme is being managed was raised by UK Statistics Authority on 2nd June.
It is not possible to further define the answers to these questions without considerable data development. This could be additional row level data being provided by the national NHS Test and Trace service, or through the development of any local intelligence sharing/Track and Trace activities.
As this document is being written, a lot of effort is being made to enable timely local answers to these questions, but the data flow will develop alongside the development and increasing capacity of the Test and Trace system itself.
The Communicable Disease Control and Health Protection Handbook defines an outbreak as either, or both, of the following:
- two or more persons with the same disease or symptoms or the same organism isolated from a diagnostic sample, who are linked through common exposure, personal characteristics, time or location
- a greater than expected rate of infection, compared with the usual background rate for the particular population and period
Furthermore, the second part of this definition is covered in Question 1 above: 'How do we monitor the general level of the outbreak in B&NES and further afield?' under wider surveillance.
Critical to identifying localised outbreaks is the ability to access very timely data, preferably within 24 hours or sooner of a suspected case being identified. All sources identified in section 1 have the potential to provide an indication of the presence of a localised outbreak. In addition, standard health protection practice at level one (local authority) provides summary intelligence (not line level) regarding outbreaks.
The draft Test and Trace notification process will notify local authorities in the case of any of the following conditions being met:
- Any positive confirmed cases where an education or childcare setting may be involved
- Any care home setting
- The NHS Test and Trace Service identifying a positive confirmed case as any of the following:
- occurring in a “complex setting” (such as a shelter or hostel)
- cases which may have a local consequence (for example, media interest or impact on public services)
- representative of a local increase in cases in a specific establishment (such as a workplace)
As a consequence, whilst timely identification of an outbreak is possible at a general level, more details on the context surrounding the outbreak will not be available until a Health Protection notification is received. These details might typically include common features, demographic characteristics, employment or education factors which may significantly influence the outbreak .
Data Integration and Future Options
The above review is developed from known data sources at the point of writing. To develop more sophisticated health surveillance methodologies, it is essential that more detailed information is provided to local authorities by key stakeholders, particularly DHSC, PHE and the new Joint Biosecurity Centre (JBC).
On the basis of parity of esteem, this should include all of the following:
- NHS number and full address for positive cases
- Detail of traced contacts at a personal level, including information about workplace or social commonalities
- Any additional data sources used in the development of national surveillance programmes (such as Google mobility or by the DWP)
- To be made available in a manner that allows for automated, machine readable sharing and access
The Joint Biosecurity Centre is a new unit specifically set up to advise central and regional bodies on the appropriate alert level, and to use data coming into the centre to help local bodies identify concerning trends in their localities.
Although it can be difficult to define the benefits of this without access to the data, some options that could be identified are the following:
- Near-instant reconciliation with Council held lists of vulnerable people (such as shielded, high risk children/young people and all Adult Social Care clients) to manage risks to our most vulnerable residents
- Integration with the Virgin Care Integrated Care Record (ICR), allowing both risk stratification (such as risk of hospitalisation) and effective live communication flow with key agencies (such as General Practice).
These methods would require appropriate data protection/privacy impact assessment.