Weekly COVID-19 Column
Rowden GP and North Wiltshire COVID-19 lead, Dr Nick Brown tells his opinion on COVID-19 topics
Flattening the curve.
I think that most people have forgotten that the measures which started 2 months ago were implemented to control the spread of Coronavirus to a level that the NHS could cope with.
Covid-19 is a highly infectious viral illness for which we have currently no specific treatment or proven vaccine and the only option to reduce spread was to enforce social isolation and distancing. Testing was, and still is, unreliable and in short supply. There were also concerns about the availability of PPE. This strategy has worked and the NHS has not been swamped, but at enormous financial, social and possibly ‘non-covid’ health cost. This cost is unsustainable and yet many lives have been sadly already lost.
In these 2 months the NHS has coped, albeit in difficult circumstances. The intensive care capacity of the NHS has been dramatically increased and so far the capacity of the 7 Nightingale Hospitals e.g. 4000 in the ExCel centre and 300 in Bristol have not been needed. Hospitals have suspended routine services to cater for the surge in urgent COVID-19 admissions and GPs and primary care services have dramatically changed their systems to reduce infection risk and increase emergency access. The less well-resourced social care system has also in most cases coped, although there is increasing concern about the inevitable consequences of this infectious virus on the frail and elderly. Locality support in villages has increased to a level not seen for decades.
The mortality curve, however you measure it, has flattened and is now falling. The reinfection ratio is below 1 and the epidemic has been brought under temporary control.
So at this stage, the Government has had a difficult choice:
- To continue the restriction and its continuing costs in an attempt to ‘bunker down’ until either the virus peters out or an effective vaccine is produced, and there is no guarantee that either of these will happen in the near future.
- To release the lock down, see an inevitable rise in infection rates but a return to some degree of commercial and social normality and attempt to keep rates below a level where health services can cope- and this might be at a significantly higher level than the peak already seen in wave one. The next month will be crucial.
There was really only one pragmatic option. Since then many individuals have taken matters into their own hands, have abandoned self-isolation and consciously or unconsciously accepted that risk. Unfortunately those who are unable to accept this risk, for whatever reason, will need to maintain isolation. Most will tread a careful path between these extremes.
So, until the virus peters out, or an effective vaccine is developed, this is the choice that we all personally face and we shouldn’t blame it all on the Government.
"I think you just have a viral infection.”
I expect that a number of readers have seen their GP in the past with a sore throat or a cough. Wondering whether they might need antibiotics, they have heard these words and have been advised to take some paracetamol and await resolution. Suddenly in these days of COVID-19, this is exactly the sort of diagnosis that none of us want to hear. In fact a good going pneumonia requiring dual antibiotics seems like ‘good news’. So what has happened and has this virus turned medicine upside-down?
Well, the problem is that we don’t really know. Clearly this novel respiratory virus is highly infectious and has spread rapidly through the world population. Significant numbers of infected patients have succumbed to the virus, many of whom, but not all, had significant pre-existing medical conditions which will have increased their susceptibility.
Most years we are subjected to an annual seasonal influenza epidemic and each year I am aware of similar tragedies amongst my patients. The symptoms and complications of COVID-19 are much the same and it is likely that this remains good advice for many individual patients, although this unfamiliar virus is clearly posing a much bigger public health and economic threat. It is possible that many have been already been exposed to the coronavirus, have either suffered a minor self-limiting illness or not felt ill at all and most importantly, have developed some immunity so won’t get it again.
If enough of us have had this experience, then the population will have ‘herd’ immunity, and the prevalence of COVID-19 will decline over weeks, months or years as the virus finds less and less susceptible victims. The UCL team recently advised that it might take 5 or 6 cycles of infection to achieve this. This is not good news as we approach the end of our first cycle.
Yet again we just don’t know. The virus was completely new so the whole world population was potentially susceptible. We have had to develop new tests to identify current infection and are developing tests for immunity. We are trying to develop a vaccine from a standing start. This process usually takes many years. There is a great deal of uncertainty and in a world which, for many of us, has been stable with a steady improvement in health and living conditions for a generation, this is causing a great deal of alarm.
This very personal experience is perhaps another demonstration that individuals, communities and countries need to change their ways if we are to avoid long-term global catastrophe.
COVID-19, Where are we now?
For the first time for a few weeks, there are signs of hope that an uncontrolled health catastrophe has been avoided in the UK, as the reported hospital death rates appear to be plateauing and even falling. It appears that in spite of the ever thorny issues of PPE and testing shortages, primarily caused by a lack of domestic manufacturing self-sufficiency, the NHS and Social Care services and their dedicated work-force and volunteers have managed to step up and cope with unprecedented circumstances.
But how has this been achieved, what is the next step, and what is the potential cost?
Clearly social distancing and isolation has played a very important role in limiting spread.
Wiltshire currently has had a low incidence with a gradual increase of COVID-19, whereas counties closer to London, with more commuting and weekend travel, even in these times of lock-down, have reported much higher exposure. Devon and Cornwall currently have a low incidence but that could change when we all head down the M4/M5 for our summer holidays. So, for rural areas, the nature and timing of the release from lock-down will have a significant effect on further local infection rates, particularly for those self- isolating vulnerable patients who have so far avoided exposure.
The NHS has coped with the threat by focussing all its resources and work force into coping with the pandemic. As a result most other medical activities have slowed or even been totally suspended. Our local hospitals have had their lowest bed occupancy rates ever but there are serious concerns that this is storing up trouble for the future. Operations are not being done. There is a strange decrease in other emergencies and cancer diagnoses and it seems that patients are reluctant to consult with their GPs or attend hospital. For some patients, this may be an overdue recalibration of ‘ill- health’ thresholds but this may mean that patients are ignoring significant symptoms. Paediatricians are concerned that young children, who relatively are more likely to suffer from serious conditions such as sepsis rather than COVID-19, may suffer from a delay in presentation and diagnosis.
I am not the right person to estimate the cost to the economy, but I am concerned that when this is all over, the verdict will be that the NHS over-reacted, at the cost of neglecting its mainstream services.
However it is much easier to be brave when the hungry lion has turned round and walked away.
Were we adequately prepared for COVID -19?
I suppose one of the surprising things about COVID -19 is that it didn't happen sooner.
For decades there have been pandemic viral threats - influenza, ‘swine’ and ‘bird’ flu, Ebola and ‘Green Monkey Disease’.
Many of you will remember the sombre national awareness campaign when HIV AIDS emerged. Throughout the world there are the ever present, but more localised, Dengue and Yellow fever and non-viral threats of Malaria, Typhoid, Cholera and pulmonary TB, to mention but a few.
Medical progress has succeeded in taming some of these threats and whilst the decline of others is a reflection of good public health standards, they re-emerge whenever society breaks down.
If this sort of thing is inevitable in a global world, could we have prepared more effectively? 3 years ago Dame Sally Davies, the Chief Medical Officer, reported that the NHS did not have enough ventilators to cope with a major respiratory virus pandemic, but it doesn’t appear that any immediate action was taken, probably because the NHS financially struggles on a day by day basis to cope with the present, let alone plan for the future. The chronic shortage of nurses and doctors is a much more obvious example of this.
When we do plan for the future, the plans are not always the right ones. In 2008 the government spent £100 million on stockpiles of Tamiflu, which has since been shown to be of limited effect and was largely wasted. We planned for Year 2K which passed uneventfully. Brexit did not happen suddenly on 31st October 2019. Individual countries are no longer self- sufficient for essential goods and to prepare means to stock pile. Consequently many products may pass their use-by dates and be wasted, as some of you may have recently discovered.
So, planning for, and reacting to, a major global situation is about balancing resilience and compromise, restriction and freedom. Different countries and their leaders have different priorities and have made different decisions and what is clear is that we are only a global world when it is mutually convenient and revert to tribalism when the going gets more difficult. There might be some quite serious global fall out following analysis of the recent sequence of events.
The current crisis has re-invigorated local social networks and some people have reported speaking to their neighbours for the first time for years. As individuals we have reacted and coped quite variably with the national requests for effective social isolation. The crisis has put a spotlight on the behavioural differences between both individual countries and individual people.
Why testing will be crucial
Firstly one of the reasons why COVID-19 has spread so quickly is that this a is a completely new virus variant and because it has never circulated amongst humans before, we have no existing immunity. Medicine had a standing start in fighting this new threat.
There are a number of potential ways to test.
- For the presence of the virus in secretions/saliva. This is the basis of the current test- the PCR test. It may fail to detect the virus in up to 30% of infected patients, sometimes due to virus levels being too low to detect at that time. It takes 3-4 days to process and may still test positive for a while after the virus has become inactive. There are some reports that quicker test is becoming available.
- Blood Antibody tests. These show that a patient has been exposed to the virus and is either mounting an immune response- Ig M or is possibly immune to further infection Ig G. This occurs perhaps 1-2 weeks after clinical infection and is part of clinical recovery. These tests, not yet available, in theory can be processed more quickly.
A very important question is what is the point of testing? A simple answer to that question is that testing must change what happens next.
The PCR test is too slow and possibly too inaccurate in early disease to change clinical management. There is no specific treatment proven to be effective against this virus and the treatment is about managing the complications as they occur.
A hospital patient with clinically suspected Covid needs to be nursed and isolated before the blood test result is known. A negative test may allow a patient to return more quickly to more normal circumstances- i.e relaxing isolation, but given that the patient will have been initially looked after in a hospital Covid area, they may become infected during treatment and will need subsequent tests! If a positive test becomes negative, then the recovering patient is no longer infectious, and probably hasn’t been for a few days.
In the community a negative PCR test would reduce the period of self-isolation by a day or two, again assuming it was accurate. Where a family is self-isolating for 2 weeks due to a suspected family member, if the suspect turns out to test negative, than family self-isolation can stop. This is of particular relevance to health care workers as a majority of health workers are not self-isolating due to personal infection but possible family exposure.
At some stage a decision will be made that restrictions can be lifted. This is the time when testing will be most valuable, particularly if an effective vaccine is not available. Patients who have high Ig G levels will have some immunity and perhaps will be safe from re-infection. For patients who have effectively self-isolated and haven’t been exposed and therefore have no immunity, this could be a dangerous time as Covid 19 is likely to continue circulating at a lower level for months or years to come.
Why is PPE necessary?
As you are aware this is a national problem and it appears that many front-line hospital and care workers looking after patients currently feel they have inadequate protection. It is clear that this PPE is in very short supply.
So why or when is it necessary and how does it work?
COVID-19 transmission can occur in 3 ways:
- Direct and visible contamination: A suit, apron or face visor are primarily used to protect the wearer from obvious contamination with body fluids. If it is not used properly it may actually increase risk. We see people on the news wearing this sort of kit and more often than not, it offers little additional protection. Celebrities who are un-willing to social-isolate seem to think that it is ok to travel in these suits but they should be reserved for health care workers who are in direct contact with infected patients.
- Direct and invisible contamination (e.g. by touch): Gloves protect the wearer from direct contamination and protect the patient as long as the gloves themselves are not contaminated. The gloves are easily contaminated and should be appropriately changed and the wearers should not touch their body, face, clothes or mask or any hard surface unnecessarily. If the wearer, for example, fiddles with a mask, the mask potentially can become contaminated bringing the virus closer to the airway, which is the way this virus gets in.
- Indirect and invisible contamination (i.e. droplet inhalation): A mask reduces inhalation of infected droplets in the air as long as it is properly fitting. It may be worn by infected individuals to capture the virus on the inside of the mask and by uninfected individual to capture the virus on the outside of the mask. If the mask doesn’t fit properly and doesn’t cover the mouth and nose effectively with a good seal, it just doesn’t work. How many times have you seen people wearing masks around their neck? The grade of the material is crucial in order to act as a filter and the protection is short term, perhaps up to 4 hours, as the filter effect of the mask can become saturated.
So PPE is not straight forward and in many situations it doesn’t offer any additional protection. Generally this equipment is disposable and cannot be reused so, with limited stocks, it is crucial that it is used appropriately and effectively.
For most people PPE is not the solution. Social distancing (2m) with regular and effective hand washing (for virus, think glitter), or if this is not possible using an alcohol gel with a concentration of more than 60%, will reduce infection by all of these routes.
The weekly Medical Column
Our current challenge- COVID-19, is a more widespread problem and the outcome is less specific but I hope that, by now, anyone reading these words is well aware of the gravity of the situation. The evidence suggests we are tracking 14 days behind Italy .
The government has issued specific guidelines - www.gov.uk/coronavirus. Anyone who breaks these rules is putting themselves, or more importantly their loved ones and others, at risk. There are too many people disregarding these guidelines and enforcement is inevitable.
As a GP I am at continuous risk of exposure and we are trying to reduce infection risk to patients and surgery staff, whilst conserving our dwindling supplies of protective equipment. We are trying to keep face-to-face contact to a minimum. If you have recently changed your telephone or email , please inform your surgery.
The care of elderly patients in care homes is a particular challenge to dedicated carers in this situation. Please respect them and do as they ask. People who normally manage to cope at home may struggle as their support network disappears. There is an updated community group directory of local organisations: www.wiltshire.gov.uk/public-health-coronavirus . www.ageukwiltshire.org.uk or 0808 196 2424 can offer help and there is national number 0800 028 8327 offering information. PLEASE CHECK THESE OUT BEFORE YOU ACTUALLY NEED HELP so you are prepared and know what to do. Keep in contact with your relatives, neighbours and local shop keepers by phone or social media.
The practices of Chippenham, Corsham and Box are working closely together with our partners Medvivo (out of hours), the community teams, the CCG and charity organisations such as Borough Lands to prepare for the next 3 months and beyond. We are working hard to set up a dedicated Respiratory assessment clinic at the New road surgery to assess patients who are having respiratory symptoms and who, after a telephone assessment, need to see a clinician . This should be operational by next week.
I would like to thank all those people, professional and volunteers , who are working over and above, providing care and preparing for the future . If anyone needs a spiritual uplift, then I recommend listening to Dougie Macleans song ' Ready for the Storm'. We are like sailors on a journey.