Public health approach to respiratory viruses including COVID-19 2022 to 2023

This publication sets out:

• the public health context as we move into autumn and winter 2022 to 2023
• our approach to responding to respiratory viruses in Wales

Given the uncertainty of the impact of respiratory viruses including COVID-19 for the forthcoming autumn/winter the purpose of this publication is to:

• highlight priority areas of focus
• set out clear expectations of the health and social care system in responding to respiratory viruses
• set out how the Welsh Government will support the health and social care system to respond efficiently and effectively
• set out how we can prepare our communities for a potentially challenging autumn/winter

Central to the approach we have outlined is our objective to protect the most vulnerable in our society from serious disease.

The approach outlined in this publication assumes we are operating in a 'COVID stable' environment. This is where we expect further waves of infection but that we do not expect these to put continued unsustainable pressure on the health and social care system. However, there are no certainties, and we may need to act rapidly to respond to changing circumstances. This could include introducing other measures and stronger advice on protective behaviours including, for example, the use of face coverings.

We face a difficult and disruptive winter in other ways due to the cost-of-living crisis and the significant pressures placed on people’s incomes and energy supplies. We will plan for this while recognising that pressure of services is much more extreme than we've seen in any previous years and could be impacted in multiple ways beyond our control.

Alongside this publication we will also be providing further technical advice on scenarios and actions needed within the health and social care system.

Welsh Government’s transition plan, Together for a safer future: Wales’ long-term COVID-19 transition from pandemic to endemic was published in March 2022. It sets out the principles upon which Wales will base its continued response to COVID-19 as we look to the future of living with the virus along with other infectious diseases, and what that will mean for public health services and protections.

The situation regarding respiratory viruses for winter 2022/23 is arguably more unclear than previous years, especially as the pattern of seasonal viruses has been significantly disrupted due to the pandemic. COVID-19 is still mutating with uncertainty around the impact of future variants in terms of transmissibility, immune response and vaccine escape, and severity. Last year’s respiratory syncytial virus (RSV) season started earlier than usual, and the same pattern has been observed this year.

Due to the current instability in the normal seasonality of the respiratory viruses caused by the introduction of COVID-19, it is not possible to predict the timing of peaks for the other respiratory viruses over the coming winter and whether they might coincide with a surge in COVID-19 cases.

The populations at risk of severe disease from COVID-19 and influenza will include individuals with underlying lung disease or those who are immunocompromised / immunosuppressed. Beyond this, the age cohorts at risk may vary depending on the types of flu or COVID-19 circulating and the pre-existing immunity within the various age cohorts in the population.

Non-pharmaceutical interventions (NPIs) are community public health measures that people can use to help slow the spread of illnesses like COVID-19 and flu.  Examples of these type of measure include staying at home when feeling unwell and wearing masks in crowded areas and health and social care settings. It is important to consider the balance of risks between COVID-19 and use of NPIs, as staying at home for long periods of time can be detrimental to physical and mental health.

The approach we continue to adopt is that COVID-19 is not over, and the transition from pandemic to endemic needs to be determined by the public health conditions at the time.

The objectives that guide our approach will continue to focus on:

• protecting the vulnerable from severe disease by enabling access to vaccination, treatments; and safeguarding against the risk of infection
• maintaining capacity to respond to localised outbreaks and in high-risk settings
• retaining effective surveillance systems to identify any deterioration in the situation such as from harmful variants and mutations of concern and
• preparing for the possible resurgence of the virus and increases in other respiratory viruses

The long-term COVID-19 plan also set out our core planning scenarios:

COVID stable

We still expect to encounter additional waves of infection. We expect new variants to emerge, and some may become dominant. But these waves will not put unsustainable pressure on the health and social care system. Vaccines and other pharmaceutical interventions are expected to remain effective in preventing serious illness. We consider this the most likely scenario.

COVID urgent

This is a possibility we are planning for. A new variant could emerge that has a high level of vaccine escape or other advantages that puts large numbers of people at risk of severe illness, for example similar to the levels we saw during the alpha wave in December 2020. This may require all of us to work together to take actions to protect others, many of which we are all now familiar with such as staying at home if we’re unwell and wearing a face covering in crowded places.

Seasonal influenza and COVID-19 viruses also have the potential to add substantially to the continued pressures within the NHS and social care, particularly if infection waves from both viruses coincide.

The timing and magnitude of potential influenza and COVID-19 infection waves for winter 2022 to 2023 are currently unknown. Scenarios for COVID-19, influenza and respiratory and RSV models have been developed for the upcoming winter season that explore how they could impact hospital admissions and bed occupancy under different conditions (for example if a usual Influenza season and Omicron-like COVID-19 wave coalesce). These scenarios have been generated to help the health and social care system to plan for most likely, reasonable and worst-case peaks.

In the context of the unknown levels and potential peaks of respiratory viruses this winter we aim to:

• Prepare communities and the health and social care system to plan and respond to the potential for COVID waves and seasonal influenza. These plans will be developed within the context of other pressures and the cost-of-living crisis.
• Deliver effective and timely influenza and COVID-19 vaccination programmes and other pharmaceutical interventions.
• Deliver an enhanced surveillance programme that: provides timely intelligence on incidence of respiratory infections; allows for rapid detection of incidents and outbreaks and supports the health and social care system to take appropriate action to reduce harm.
• Deliver testing plans that protect the more vulnerable, and support our surveillance plans. This is supported by prioritising whole genome sequencing that allows for detection of new COVID-19 variants and drift/shift of influenza viruses aligned to severity of illness.
• Ensure vulnerable settings such as health and social care, prisons and other critical services, are supported by appropriate guidance on management of respiratory outbreaks.
• Deliver clear and effective communication, supporting the public to reduce personal risk of respiratory viral illness.
• Ensure guidance and communications takes account of the cost-of-living crisis and its impact on individual and organisational actions.
• Take collective action to minimise wider harms incurred through our response to respiratory outbreaks or epidemics.

In a COVID urgent scenario, these aims would remain, but we would provide further guidance as appropriate, detailing any additional interventions.

Effective and routine respiratory disease surveillance is an important feature of the health protection system in Wales. The intelligence we collect will help guide investment decisions and policy choices that will need to be made this winter.  

Our aim is to deliver an effective combined surveillance system that provides timely information to aid effective risk assessment and risk management decisions to reduce harm from COVID-19 and other respiratory viruses. This will be more critical this winter with mass community testing for COVID-19 having ended in April 2022.

This winter we will be strengthening our surveillance system to identify any deterioration in the situation such as from harmful variants of concern and other respiratory viruses. The surveillance system will help to determine whether Wales has moved from a COVID stable to a COVID urgent state, either through the epidemiological indicators or from genomic surveillance indicating the presence of a more severe variant. For autumn/winter 2022 the focus is on enhancing and establishing more robust community and hospital surveillance systems.

Work is on-going to include a greater number of samples for people with respiratory symptoms from a larger and more representative set of GP practices and pharmacies that will also consider vulnerable groups and inequalities. This larger system will aim to involve 50 GP practices covering a population of around 500,000. New surveillance networks in care homes and pharmacies will further increase samples and add to this community intelligence. Public Health Wales’s (PHW) aim is for GP and pharmacy surveillance combined in the longer term to provide 25,000 samples a year with the aim to reach 6,500 cases per year (125 per week) across Wales in 2022/23.

During autumn/winter, we will also continue to provide multiplex testing for symptomatic care home residents and prisoners. Multiplex tests will diagnose COVID-19 and other respiratory viruses including influenza and RSV. This will enhance our surveillance alongside protecting the more vulnerable within closed settings and help us manage outbreaks based on the respiratory virus identified.  

In addition, the proposal during autumn/winter is to offer PCR multiplex testing for symptomatic front-line health and social care workers working in high-risk settings, as set out in the section 'Protecting our more vulnerable'. This population is, to a good extent, representative of the working age population and can add to other community surveillance sources.

Hospital admissions with acute respiratory symptoms will also have a standard set of pathogen tests and data collected, with a subset of emergency department sites collecting a wider range of information. This enables monitoring of the absolute and relative burden of respiratory infections and gives a signal on vaccine effectiveness.

During the pandemic, Wales has developed and rapidly upscaled a world-class capability for genomic surveillance and virological characterisation. We recognise the need for continued sequencing and genomic analysis this autumn/winter and positive samples from the community and hospital testing will be characterised and sequenced to detect changes in circulating pathogens and their variants, understand transmission, and provide information for vaccination composition and strategies. This will support continuation of our contribution to global surveillance.

To assure timely and accurate interpretation of our surveillance data we intend to continue to utilise local intelligence collected from our established professional networks. A number of national multi-disciplinary health and public protection groups will continue to meet regularly to consider local and regional intelligence in relation to trends in national surveillance data. This will build on the information we receive from the Office for National Statistics (ONS) COVID-19 survey on a weekly basis that also provides comparisons across the UK nations. This will support an evidence-based approach to decision making.  The ONS and other data will be regularly published in Technical Advisory Cell papers which are published on the Welsh Government’s website. Data is also included from the regular sampling of levels of COVID-19 in wastewater from across Wales to further support our intelligence.

In September 2020 Welsh Government began sampling wastewater from 19 Wastewater Treatment Works (WwTW) from across Wales in order to detect the levels of COVID-19. Since then, the programme has undertaken work not only to expand the coverage of the wastewater monitoring but also to improve the testing methodology to make it more representative of the catchments served. Welsh Government intends to monitor up to 50 WwTW catchments across Wales in order to assist in the early detection of changing viral levels and the potential scale of outbreaks to help inform any public health action taken in the management of the pandemic and beyond.

Managing Incidents and Outbreaks

The Communicable Disease Outbreak Plan for Wales (phw.nhs.wales) ('The Wales Outbreak Plan') and The Framework for the Control of an Outbreak or Incident of Infection in Acute Healthcare Premises in Wales (phw.nhs.wales) provide the template for managing all communicable disease incidents and outbreaks, including respiratory outbreaks, with public health implications across Wales.

Responsibility for managing incidents and outbreaks is shared by all the organisations who are members of the outbreak control team (OCT) or incident management team (IMT). Specifically, the responsibility for decisions made by the OCT/IMT is collectively owned by all organisations represented on the OCT/IMT. Individual organisations are then responsible for carrying out the actions assigned to them as agreed at OCT/IMT meetings.

If an incident becomes an outbreak, an outbreak should be declared, the IMT dissolved, and an OCT formed.

The primary objective in the management of an outbreak is to protect public health by identifying the source and/or main determinants of the outbreak and implementing necessary measures to prevent further spread or recurrence of the infection.

The secondary objective is to improve surveillance, refine outbreak management, add to the evidence collection, and learn lessons to improve communicable disease control for the future.

Vaccination remains our first line of defence for COVID-19 and flu and is a critical part of our response. It is the most important action an individual can take to protect themselves and others. COVID-19 vaccines have been developed quickly and safely during the pandemic, saved thousands of lives, and significantly weakened the link between the infection resulting in serious disease, hospitalisations and death. This is why it is so important for everyone to take up their offer of a vaccine and ensure they have the protection it offers from current and future variants.

Vaccination

The winter respiratory vaccination strategy outlines how we are integrating the COVID-19 and influenza vaccination programmes this year with a view to maximising uptake of both vaccines to protect individuals, communities and the health and care system in Wales this winter. This is the first major step of our vaccination transformation programme, which is described in more detail in the Winter respiratory vaccination strategy: autumn and winter 2022 to 2023.

The strategy outlines the following three key priorities:

• Protecting those at greatest risk.
• Protecting children and young people.
• Nobody left behind – the opportunity for eligible individuals to come forward for their vaccine will not expire. The NHS will continue to facilitate high uptake levels by making the vaccines universally available and widely accessible.

The Joint Committee on Vaccination Immunisation (JCVI) are an independent expert advisory committee that advises health departments on immunisation and provide recommendation for vaccination schedules. Their published advice for the autumn booster programme for 2022, notes that programmes should primarily use one vaccine type for boosters (bivalent vaccines) for operational simplicity. This advice has been supported and implemented by Welsh Government.

Nobody left behind

Vaccine equity remains a key principle of Wales vaccination programme. The ‘nobody left behind’ principle, embedded into our vaccination strategy, is built on the premise that everyone should have fair access and fair opportunity to take up the offer of a COVID-19 vaccination.

We know the health harms from COVID-19 have not affected people in Wales equally and the NHS has worked closely with community groups and leaders, responding to local issues such as:

• vaccine mis-information leading to hesitancy among some community groups
• lack of transport to vaccination centres resulting in some being unable to attend a vaccination appointment
• mistrust of health professionals leading to some people feeling anxious about attending mass vaccination centre
• time constraints leading to others finding they could not prioritise a vaccination appointment

COVID-19 vaccination

All eligible cohorts listed below will be invited for their booster before the 30 November 2022 with the first jabs in arms vaccines having been taken up in early September 2022. 

• residents and staff working in care homes for older adults
• frontline health and social care workers
• all adults aged 50 years and over
• persons aged 5 to 49 years in a clinical risk group, including pregnant women
• persons aged 5 to 49 years who are household contacts of people with immunosuppression, as defined in the Green Book
• persons aged 16 to 49 who are carers

Flu vaccination

The JCVI also issues advice for flu vaccine and our NHS has plans in place to offer the vaccine to the following adults in line with this: 

• all adults aged 50 years and older 
• staff with regular client contact in nursing homes and care homes
• staff providing frontline NHS/Primary care services, healthcare workers with direct patient contact
• staff providing domiciliary care 
• people aged six months to 49 years in a clinical risk group 
• individuals experiencing homelessness 
• pregnant women 
• carers 
• people with a learning disability 
• people with a severe mental illness 

Our ambition is to:

• achieve 75% take up across the board for both the COVID-19 and flu vaccines     
• achieve 80% take up for the chronic obstructive pulmonary disease risk group for both the COVID-19 and flu vaccine

Looking ahead

The integration of the COVID-19 and flu programmes this year – through the winter respiratory vaccination programme – is the first step in our vaccination transformation programme. The vaccination transformation programme is how we look at the provision of our vaccination services as a whole and for the longer term to ensure our services are fit for the future.

Later in the autumn we will publish a National Immunisation Framework for Wales. The framework is being developed on a co-construction basis with the NHS. Through this process we will identify and use what works well currently and the lessons from the pandemic to transition to a position of improved business as usual through integrating all current vaccination programmes. The framework will be applied across the NHS in Wales so that the people of Wales have an identifiable and seamless provision to obtain their vaccination to ensure protection from viruses.    

Supporting our communities to keep well this winter

Respiratory infections can spread easily between people.

Symptoms include:

• continuous cough
• high temperature, fever or chills
• loss of, or change in, your normal sense of taste or smell
• 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

Our advice and approach will continue to focus on enabling and promoting individual behaviours to protect ourselves, each other and particularly the more vulnerable as these can have significant benefits to reducing transmission of respiratory viruses.

Protective behaviours include:

• get vaccinated
• stay at home if you’re unwell and limit your contact with others
• maintain good hand hygiene
• wear a face covering in crowded indoor or enclosed places, including health and care settings
• meet others outdoors
• when indoors, increase ventilation and let fresh air in where possible

Maintaining these behaviours which we have become familiar with, alongside appropriate environmental protections, can have significant benefits that go beyond reducing the spread of COVID-19. Continuing these behaviours will help reduce impact of future waves of coronavirus, whilst also reducing the impacts from other respiratory infections.

The key message to protect yourself, your family and others this winter is to take up the vaccination offer, if eligible and stay up to date with your COVID-19 and flu vaccinations.

Advice for individuals

Our advice for people with symptoms of a respiratory infection is to:

• Get plenty of rest and drink water to keep hydrated.
• Use medications such as paracetamol to help with symptoms. Antibiotics are not recommended for viral respiratory infections because they will not relieve symptoms or speed up recovery.
• Stay at home and avoid contact with others until you no longer have a high temperature or until you feel better. You could ask friends, family, or neighbours to get food and other essentials for you.
• Work from home wherever possible. If you cannot work from home, talk to your employer about options.
• If you've been asked to attend a medical or dental appointment in person, tell them about your symptoms.
• Tell people you have recently been in contact with that you're feeling unwell. This means they can be aware of signs or symptoms.

If you are concerned about your symptoms, they are worsening, or you can no longer manage at home, seek medical advice by contacting your GP or NHS 111. In an emergency dial 999.

Advice for businesses and employers

Businesses, employers and event organisers should consider the risks associated with COVID-19 in the same way as they do for all other communicable diseases (for example flu and norovirus).

We advise all businesses, employers and event organisers to continue to implement effective public health control measures. These will help protect workers, contractors, visitors and customers from exposure and prevent the spread of coronavirus. The most effective way of preventing the spread of any communicable disease in any premises is to prevent the virus being present in the first place. 

Employers should consider what action they should take if a staff member is displaying any symptoms of a communicable disease (such as flu, coronavirus or norovirus) or have tested positive for coronavirus. What is reasonable will depend on a number of factors, including whether it is feasible for the work to be carried out from home.

Wherever possible, Welsh Government would encourage employers to discuss and agree any changes to absence management with the workforce and with trade unions prior to any changes being implemented. 

Advice for schools

Schools

The Public Heath Advice for Schools: Coronavirus offers flexibility to determine what is required to manage risks. It remains important for schools to consider what they can do to reduce the spread of COVID-19 and protect their learners and staff, including any additional protections for those who are more vulnerable. By continuing to implement public health control measures, schools and settings will help keep the spread of the virus low, improve public and staff confidence and minimise the potential of further disruption.

With increasing numbers of people vaccinated and everyone’s continued efforts the risks from COVID-19 should now be considered in the same context as other communicable diseases risks (for example flu and norovirus).

There is additional advice for staff and pupils of special educational schools, based on the objective of protecting the more vulnerable and reducing the risk of transmission to those who are at highest risk of adverse outcomes and within closed settings. Further details can be found in the section 'Protecting our more vulnerable' (Test, Trace, Protect).

Additional advice on the safe operation of schools.

Health

COVID-19 has placed sustained pressure on the NHS in Wales, both from people being treated directly for COVID-19, and people testing positive but being treated for other reasons, along with staff absence due to infection, isolation or family illness. It may be that COVID-19 continues to add 2-10% additional pressure onto the NHS in terms of admissions, staff absences, and increased Infection Prevention & Control (IPC), which represents pressure that was not in the system before 2020.  

The NHS in Wales is now moving towards the autumn/winter of 2022 to 2023, with an integrated vaccination programme in place, but with significant challenges to address waiting lists, the demands of winter and other pressures. Planning for the NHS this winter has been integrated into existing planning and is set out in the NHS Planning Framework and commenced many months ago. Planning for seasonal peaks in pressure is a year-round exercise and development of interventions that will enable additional resilience we know commenced many months ago. A key focus has been to increase system resilience of the urgent and emergency care services this winter.

£146 million for the Health and Social Care Regional Integration Fund (RIF) is in the system to support a coordinated social care and NHS response to key priorities. A significant proportion of the fund is committed to three models of care which already make a direct contribution to the autumn and winter priorities, those models being:

• community based care - prevention and community coordination
• community based care – complex care closer to home
• home from hospital services

These models of care include projects that are helping people to stay well at home, making effective use of community assets, resources and services to help prevent loneliness and isolation, poor health and the need for hospitalisation. There are also projects that are directly providing additional step-down beds and equivalent services in the community including intermediate care services and reablement support to help people return to their own home to recover safely in their own environment.  

IPC measures remain a key component of practice to ensure the continued safe return of all healthcare services and the reduction of transmission in healthcare settings of COVID-19 and other infections, such as influenza, RSV and norovirus.

Our IPC measures, including the hospital patient testing framework will continue to support the NHS this autumn/winter. NHS bodies are also required to demonstrate they have robust processes, including surge plans, in place to deal with seasonal pressures resulting from a rise in respiratory illnesses, such as flu or RSV. These plans will need to include a focus on vaccination/immunisation uptake, the ability to assess and treat patients in the community to avoid preventable admissions and plans to increase access to critical care level respiratory support. In addition, these plans should be seen as live documents that drive improvement are reviewed regularly to ensure they remain appropriate, up to date and responsive new evidence and circumstances as they arise.

Infection Prevention & Control (IPC) advice for health and social staff

The current Public Health Wales COVID-19 IPC Guidance sets out IPC measures to prevent transmission of COVID-19 in health and care settings in Wales. This guidance should be read in conjunction with the National Infection Prevention and Control Manual Wales, which includes guidance on the management of other winter viruses.

The patient testing framework sets out national guidance for testing for patients for admissions and discharge and includes for this autumn and winter the use of multiplex testing. The guidance is based on the best scientific, public health and expert evidence available but also recognises the importance for local decisions to be made about where or when testing may need to be increased or decreased depending on nosocomial rates, community transmission rates, or vulnerability of patients.

Vaccination programmes both for COVID-19 and seasonal flu remain a critical part of our infection prevention and control plans.  High levels of vaccination amongst the workforce both to maintain the health and wellbeing of our workforce, and to prevent onward transmission of infection to patients and colleagues.  This will also help to maintain our staffing levels by minimising avoidable illness and so avoiding increasing the pressure on colleagues who remain in work.  We will be working with social partners to encourage vaccination across our workforce.

Social care

This autumn and winter we will continue to support social care including care homes on infection and prevention control measures. This will include continuing to provide free personal protective equipment (PPE) and access to testing. It is recommended that all symptomatic adult care home residents and staff have a multiplex test that will diagnose COVID-19 and other respiratory viruses including influenza and RSV and ensure prompt implementation of protective measures. For a diagnosis of influenza this could mean the prescribing of antivirals for both treatment and prevention against infection. 

Asymptomatic testing for social care staff was paused on 8 September 2022. However, we have plans in place to re-introduce if required this winter.

Visitors to care homes

Visitors to care homes should be welcomed, encouraged and enabled when there is no outbreak at the care home. Visiting arrangements should be as open and flexible as possible. With regular asymptomatic testing being paused for social care settings, visitors will no longer need to take a lateral flow test (LFT) before visiting a care home.

Anyone with symptoms of COVID-19 or who is a close contact of a positive case of COVID-19 in the last 10 days,or has had any other respiratory virus symptoms is asked to not attend the care home during this period of time.

Care homes should take a risk-based approach to supporting visiting during an outbreak/incident.  If a care home is in outbreak/incident status decisions about supporting visitors into the home should be informed by the characteristics of the outbreak and advice from the local health and public protection teams supporting that home. In some circumstances it maybe proportionate to introduce additional control measures to enable routine visiting to continue. An example would be where infection is confined to a defined building or floor of the home or confined to kitchen staff.

Essential visitors can continue to visit during an outbreak/incident.  People may nominate 2 essential visitors in order to give greater flexibility without significantly increasing footfall into the home during an outbreak. They may visit separately or at the same time.

The declaration and management of outbreaks of COVID-19 within care homes has been brought in line with existing respiratory infection guidance so that an incident/outbreak is only declared if two or more patients or staff cases of COVID-19 occur within a specific setting where nosocomial infection and ongoing transmission is suspected.  For an outbreak to be declared over, there should be no new outbreak-associated symptomatic or confirmed COVID-19 cases for a minimum period of at least 14 days.

We have retained infrastructure to support outbreaks in care homes and other settings. This includes three Mobile Testing units, health boards testing teams and LFD supplies and systems.  

Prisons

Health boards providing health services within prisons are expected to include prison health services within their own winter planning arrangements. Public Health Wales (PHW) will continue to support through the production of surveillance reports to provide intelligence on incidents and outbreaks and will remain in close contact with each prison to support and advise on COVID-safe regime delivery.

PHW plan to rapidly review and adapt for Wales any updated guidance on the management of communicable diseases in prisons and distribute to all prisons and prison health care providers.

Health boards will need to ensure sufficient resource is allocated to prison healthcare teams in remand prisons as these will need to keep up vaccination pace for the entire winter due to their rapid turnover of admissions.

Some people are more at risk of severe harm and hospitalisation if they contract respiratory viruses. They may also suffer more frequent infections which may impact particularly on those with an underlying health disease. Antiviral medicines can help prevent severe illness in people and prevent people from needing to go into hospital if they are taken soon after infection occurs.

Pharmaceutical Interventions

Antiviral medicines for the treatment of flu

Once a vulnerable person becomes infected then antiviral agents such as oseltamivir and zanamivir are recommended by the National Institute for Health and Care Excellence (NICE) for the treatment off flu in adults and children if:

• national surveillance schemes indicate that flu virus A or B is circulating
• the person is in an 'at-risk' group; and
• the person presents with an influenza-like illness and can start treatment within 48 hours (or within 36 hours for zanamivir treatment in children) of the onset of symptoms

Someone is defined being in a at risk group if they:

• are aged over 65
• have a chronic respiratory (including asthma and chronic obstructive pulmonary disease) heart, renal or liver disease
• have a chronic neurological condition
• diabetes mellitus or
• a compromised immune system

NICE has also provided guidance stating that oseltamivir and zanamivir may be used for prophylaxis (a treatment given to prevent disease) to people in at-risk groups following exposure to a person in the same household or residential setting with flu-like illness when flu is circulating in the community.

As per NICE guidance, prophylaxis should be issued if the contact is not adequately protected by vaccination, either because the vaccination is not well matched to the circulating strain, or there has been less than 14 days between vaccination and date of first contact with influenza. In addition, the guidance also states that if the individual has been exposed as part of a localised outbreak (such as in a care home), antiviral prophylaxis may be given regardless of vaccination status.

Antiviral medicines for treatment of COVID-19

People who are at high risk of becoming severely ill due to COVID-19 are eligible for treatment with antiviral or neutralising monoclonal antibody therapies in accordance with the UK wide clinical access policy. Those at highest risk and eligible for treatment are people who have: 

• chromosomal disorders that affect the immune system, including Down’s syndrome
• certain types of cancer, or have had a cancer removed in the last 12 months
• had either radiotherapy or chemotherapy in the last 12 months
• sickle cell disease
• certain conditions affecting the blood or have received a haematological stem cell transplant
• chronic kidney disease (CKD) stage 4 or 5
• severe liver disease
• had an organ transplant 
• certain autoimmune conditions or inflammatory conditions, such as rheumatoid arthritis or inflammatory bowel disease who may be receiving certain medications
• HIV or AIDS
• a rare neurological condition (such as multiple sclerosis, Huntington’s disease, motor neurone disease or myasthenia gravis)
• an impaired immune system due to either a condition or certain medications 

If people in these groups test positive for COVID-19 and report their lateral flow test result they will usually be contacted within 48 hours and offered treatment via text message or telephone call from the National Antiviral Service. 

A clinician in the antiviral service will offer eligible people treatment with the antiviral medicines nirmatrelvir and ritonavir, or molnupiravir, or where antiviral treatments are not appropriate by referral to a health board for neutralising monoclonal antibody treatment (sotrovimab) that is given through your arm in a single appointment usually in a hospital.

Test Trace Protect (TTP)

The focus for our testing and contact tracing teams is now targeted to protect our more vulnerable, inform surveillance, support outbreaks and plan for a potential wave in cases and a COVID urgent scenario. We are now providing multiplex PCR tests within a number of settings. These tests can diagnose other respiratory viruses apart from COVID-19, such as flu and respiratory syncytial virus (RSV). Testing supports access to pharmaceutical interventions to protect those who remain vulnerable to negative outcomes of infection.

Our TTP approach for this autumn/winter includes:

1. Accepting COVID-19 as disease that is integrated into our public health response alongside other communicable diseases.
2. Focusing on promoting individual behaviours and management of symptoms – stay at home when ill (especially important for health and social care workers), limit contact with others, take extra precautions when meeting with someone vulnerable and wear a face covering if it is necessary to leave the house.
3. Contact tracing will be targeted on protecting the most vulnerable and supporting the response to local outbreaks and clusters (as directed by regional health boards), as well as maintaining surge capacity in the event of a COVID urgent scenario.
4. Protecting those who remain vulnerable to negative outcomes of COVID-19 infection, those who are eligible for treatments and/or could be vulnerable to rapid spread of new variants (care home residents) and use our available testing infrastructure to support responses to wider respiratory illnesses.

For the majority of people, this means if they have symptoms of a respiratory infection, such as COVID-19, and they have a high temperature or do not feel well enough to go to work or carry out normal activities, they are advised to try to stay at home and avoid contact with other people.

The targeted testing arrangements in place in a COVID stable position this winter are set out below:

• PCR and/or LFT in accordance with the patient testing framework and clinical judgement
• LFT and PCR tests for those eligible for COVID-19 treatments
• PCR and LFT tests for outbreak management
• LFT for symptomatic health and social care staff working in the community including domiciliary care workers, social care workers and primary care staff. 

Alongside LFT and COVID-19 PCR tests we are also this winter increasing access for multiplex tests that also detect other respiratory viruses as well as COVID-19. These are already available for symptomatic: 

• care home residents
• prisoners
• some patients under the patient testing framework

For autumn and winter, they will also be extended for symptomatic staff working in:

• hospitals (patient-facing staff)
• care homes
• hospices
• special schools (residential settings)
• prisons

Testing arrangements for discharge from hospital to a care home remain in place and are based on symptom resolution and the time elapsed from a positive test. The guidance in the patient testing framework is that asymptomatic patients who have not previously tested positive for COVID-19 should be tested with an LFT within 24 hours of planned discharge to a care facility.

We have also retained a level of infrastructure and tools to respond to a wave in cases and for a COVID urgent scenario. These include a retained supply of LFT tests, laboratory capacity and logistic systems that could potentially provide additional targeted access to tests to help reduce transmission, support behaviours to protect the vulnerable and understand any changes to the virus and impact of any new variant.

Communications activity continues to adopt an insight led, multi-media approach to encourage individuals to take personal responsibility to minimise transmission of COVID-19 and other respiratory diseases.

To ensure people in Wales receive clear, consistent public health advice and information, we have and continue to use a wide range of communications channels, including advertising, social media and digital communications, press and media briefings.

The Welsh Government and PHW will continue to work in partnership to deliver national public health communication campaigns, providing materials to partners at Local Health Board and local authority level to promote national messages at a local level. We will also share materials with partners such as charities and the voluntary sector to reach specific key audiences.

As we move into autumn/winter, the' Keep Wales Safe' campaign activity will evolve and develop to include messages on broader respiratory illnesses. The campaign will focus on daily protective behaviours everyone can do to prevent the spread of respiratory viruses in order to protect those people at most risk. The messaging will be sensitive to the increased cost of living,and focus on behaviours that are easy and simple for everyone to maintain. Flexibility has been built into the campaign, to ensure that if we move to a COVID urgent scenario, communications activity can be ramped up in terms of frequency, visibility and tone.

PHW will lead the delivery of the respiratory disease vaccination programme, supported with a national public information campaign. The campaign aims to increase uptake of flu and COVID-19 vaccines, with a specific focus on vulnerable groups and those experiencing disadvantage.

Services within NHS Wales are likely to be under increased pressure as we move into autumn/winter. To help ease pressures in accessing NHS services, the Welsh Government will continue leading and delivering the 'Help Us Help You' campaign. The campaign aims to signpost the range of ways people can access NHS services appropriately so they can receive the right help, at the right place, first time. The campaign also focuses on encouraging self-care, use of local pharmacies for many common conditions and promotion of support for mental health and wellbeing, by using the strapline ‘Better health starts with you’.

To support this activity the Welsh Ambulance Service Trust will launch a campaign to promote the national NHS 111 Wales service. The two campaigns are being coordinated to ensure maximum impact at the most critical periods during the winter months.

Across all campaigns, we will continue to tailor our communications to reach diverse audiences, recognising the need to engage with, for example, young adults and Black Asian and Minority Ethnic communities through specific channels, tailored communications and trusted voices.

Other challenges face us this winter with the cost-of-living crisis and we will be developing practical advice and guidance to support individuals and communities to help keep

We continue to have in place monitoring and oversight arrangements to review the surveillance data and intelligence set out in the 'Surveillance' section. This builds on the approach adopted throughout the pandemic to combining a wider range of scientific evidence and analysis from different disciplines alongside local intelligence and surveillance. This winter our oversight will also cover other respiratory viruses as well as COVID-19.

We are expecting during the winter to manage outbreaks through the arrangements we have in place under the outbreak control plan and respond to further waves of infection. There is also the potential that a new COVID-19 variant may emerge which will create a surge in cases and possibly a higher level of flu than we have seen over the past two years as other respiratory viruses re-emerge.

We have retained a level of infrastructure and tools to adapt and respond when necessary, including a higher level of infection and prevention control measures, more targeted testing, vaccination surge plans and issuing of stronger guidance to the public on measures they can take to protect themselves and others. We hope that this increased capability will not be needed over the winter but will be prepared with partners in the health and social care system to scale up if needed.