Blog posts

Patient outcomes following emergency admission to hospital for COVID-19 compared with influenza

Our recent study in the journal Thorax examined patient outcomes following emergency admission to hospital for COVID-19 compared with influenza. We used routinely collected primary and secondary care data. Outcomes, measured for 90 days follow-up after discharge were length of stay in hospital, mortality, emergency readmission and primary care activity.

The study included 5132 patients admitted to hospital as an emergency, with COVID-19 and influenza cohorts comprising 3799 and 1333 patients respectively. Patients in the COVID-19 cohort were more likely to stay in hospital longer than 10 days (OR 3.91, 95% CI 3.14 to 4.65); and more likely to die in hospital (OR 11.85, 95% CI 8.58 to 16.86) and within 90 days of discharge (OR 7.92, 95% CI 6.20 to 10.25). For those who survived, rates of emergency readmission within 90 days were comparable between COVID-19 and influenza cohorts (OR 1.07, 95% CI 0.89 to 1.29), while primary care activity was greater among the COVID-19 cohort (incidence rate ratio 1.30, 95% CI 1.23 to 1.37).

We concluded that patients admitted for COVID-19 were more likely to die, more likely to stay in hospital for over 10 days and interact more with primary care after discharge, than patients admitted for influenza. However, readmission rates were similar for both groups. These findings, while situated in the context of the first wave of COVID-19, with the associated pressures on the health system, can inform health service planning for subsequent waves of COVID-19, and show that patients with COVID-19 interact more with healthcare services as well as having poorer outcomes than those with influenza.

The findings relate to 2020, a period before Covid-19 vaccination began and when different variants of SARS-CoV-2 were circulating in the UK. We aim to update the analysis to see how Covid-19 outcomes have changed since that period compared to outcomes from influenza.

Covid-19 rates are increasing again in the UK – What does the public need to know?

Why are so many people coming down with Covid again?

The current wave of Covid-19 infections is being caused by highly infectious subvariants (BA.4 and BA.5) of the Omicron variant that entered the UK in late 2021. These subvariants are more infectious than the previous variants of the coronavirus that the UK has faced. They are also more likely to cause reinfections. Other factors increasing the number of infections include greater mixing of people now that Covid-19 measures in the UK have ended and reduced protection from infection from vaccines because many people are more than six months since their last Covid-19 vaccination.

Are the new variants worse than the other variants?

Although they are more infectious than other variants, the new subvariants of Omicron do not cause more severe disease and on average, they probably cause a milder illness. However, because of the very large number of infections caused by these subvariants, some people will have a serious illness with a risk of being admitted to hospital or dying. The good news though is that vaccines still work very well at reducing the risk of serious illness and death. The number of deaths from Covid-19 in England is very low due to this protection given by vaccines.

How bad could this new wave get?

We will see a further increase in cases and hospitalisations during July. After July, we should see a decline in both cases and hospitalisations as we saw with the previous two Omicron waves in January and April. Although we will see additional pressures on the NHS, the number of deaths will remain much lower than in January 2021 when deaths from Covid-19 in the UK peaked.

Could any restrictions be brought back and if so, what?

It’s very unlikely the government will bring in any new legal restrictions but they may offer public health advice on the use of face masks in indoor settings and the importance of good ventilation in reducing the risk of infection. They will also encourage people to take up the offer of Covid-19 vaccination if they are eligible for a booster or have not yet had a full course of vaccines.

Wasn’t the colder season the worst time for Covid? How come it’s now spreading in the hot weather?

Respiratory infections are usually worse in winter when the weather is colder and people spend more times indoors. With Covid-19, however, we have seen new virus variants emerge that are highly infectious and which can increase the number of infections, including in the summer.

If I’ve already had Covid this year am I just as likely to catch this new variant, or if I do might the symptoms be milder?

People who have already had an infection this year are less likely to get a second infection. If they do get a second infection, it is likely to be milder, particularly if they are fully vaccinated. However, for some people, a second infection can be more severe than their first infection.

How could the new Covid surge affect the summer holidays?

The UK government has no plans to introduce restrictions on travel or requirements for Covid-19 testing like those we saw in previous years. However, if there is a large increase in the number of Covid-19 infections, it is possible some countries may introduce new measures. However, at this point, I would say this is unlikely to happen.

Will they bring back airport testing, and if not how easily could we catch Covid if there are positive people on the flight?

There are no plans to bring back Covid-19 testing before flights. It’s unlikely this will happen in the UK unless the number of serious Covid-19 cases become so high, the NHS is unable to cope. The best way to prevent this from happening is for everyone to be fully vaccinated. The risks of catching Covid-19 are probably higher in crowded airport terminals than on an airplane because of the ventilation and air filtration systems that modern airplanes use. If people are unwell, they should avoid travelling so that they do not infect others.

I’m back to working next to others in a busy office. What precautions should I take?

Try to ensure that the room is well ventilated. Ideally, everyone in the office should be fully vaccinated. You can also wear a face mask (preferably an FFP2 mask that provides better protection). If anyone is unwell with a possible Covid-19 infection, they should stay at home and not come into work. Employers have a duty of care to their staff and should not ask employees to come to work if they are unwell and may pass on a Covid-19 infection to others.

Am I still protected by the vaccine and booster?

If you are fully vaccinated, including with a booster, you are still very well protected against serious illness and death, although you can still be infected. When another booster is offered in the Autumn, you should take up this offer if you are in an eligible group.

When will another booster be available for people under 75 and will it be updated to protect against the new variant?

Another Covid-19 vaccine booster will be available in the Autumn. This will be offered to people living in care home for older adults and their staff. Frontline health and social care workers and people aged 65 years and over will also be eligible for a booster in the Autumn. Some adults aged 16 to 64 years who are in a clinical risk group will also be eligible for a booster but the government has not yet confirmed what medical conditions will make people eligible. There are now updated vaccines being tested that target Omicron. The government has not yet approved these updated vaccines for use in the UK but if the results from clinical studies are good, it’s very likely these vaccines will be offered in place of the original vaccines for the Autumn booster programme.

Why is there talk of an even worst Covid wave in the Autumn? What might happen?

We had a very high number of hospitalisations and deaths from Covid-19 in the winter of 2020-21. In the winter of 2021-22, thanks to vaccines, the number of hospitalisations and deaths was much lower. It’s very likely that the UK will experience another wave of Covid-19 in the Autumn and Winter when the weather is cooler and people spend more time indoors. This increase in Covid-19 cases may occur at the same time as a large flu epidemic. To reduce the impact of flu and Covid-19 on people’s health and the NHS, it’s essential that eligible people take up the offer of a flu vaccine and that as many people as possible are fully vaccinated against Covid-19, including with any boosters that are offered later this year.

A version of this article was first published in the Daily Mirror.

Healthcare workers potentially exposed to HIV: an update

Despite the very low risk of seroconversion, occupational HIV exposure is a very stressful situation. Our new article in the Journal of the Royal Society of Medicine provides guidance on how such exposures should be managed to minimise risks and improve health outcomes for staff exposed to contaminated body fluids.

Careful risk communication can help in addressing anxiety. Pre-Exposure Prophylaxis (PEP) is seldom indicated for occupational exposures if the index case is of unknown HIV status, as the transmission risk is very low. PEP is indicated to reduce the transmission risk following high-risk incidents – exposures where the index case is known to be HIV-positive with a detectable viral load – and is most effective if started promptly.

Why we need to put an end to the GANFYD culture in the UK

One of the causes of increased workload in general practice are the many requests that doctors get for letters from patients or from external organisations. It’s now so common that doctors have coined a term for it: GANFYD – Get A Note From Your Doctor.

It’s seems that large sections of society can’t function without these “letters from doctors”. Instead of using common sense or employing their own clinical advisers, external organisations make repeated requests to NHS doctors for letters which are not at all needed.

Often the worst offenders come from the public sector – e.g. universities who seem to look upon NHS general practice as a source of free occupational health advice for their students. Universities never – of course – offer to pay for this advice they get from NHS GPs.

Instead, university requests will come with a mealy-mouthed statement that any fee is the responsibility of the student. Like doctors are going to impose heavy fees on impoverished students who already have large debts and are who are often living in poverty.

Local government and schools are other frequent offenders, requesting letters for issues they could easily resolve themselves using some common sense. And perhaps surprisingly, the NHS is also a frequent offender (you would think that NHS Trusts would know better).

What’s the solution? I have concluded that to address the GANFYD problem, we need to remember the adage “money talks while bullshit walks”. But don’t charge patients. Change NHS regulations so the (suitably large fee) is the responsibility of the organisation making the request.

The NHS is under great pressure and we urgently need to do everything we can to reduce unnecessary work in the NHS so that NHS staff can focus on clinical work.

Impact of COVID-19 on primary care contacts with children and young people in England

During the COVID-19 pandemic, health systems globally shifted towards treating COVID-19 infection in adults and minimising use of health services for other patients, including children and young people (CYP), who were less susceptible to severe COVID-19. In March 2020, the NHS recommended remote triaging before any face-to-face contact to reduce infection risk.

The UK Government announced a nationwide lockdown in England from 23 March 2020, and the public was advised to stay at home to limit transmission of COVID-19 and avoid strain on health resources. GPs were asked to prioritise consultations for urgent and serious conditions, and suspend routine appointments for planned or preventive care.

Children’s access to primary care is highly sensitive to health system changes. We examined the impact of COVID-19 on GP contacts with children and young people (CYP) in England. We used a longitudinal trends analysis was undertaken using electronic health records from the Clinical Practice Research Datalink (CPRD) database.

GP contacts fell 41% during the first lockdown compared with previous years. Children aged 1–14 years had greater falls in total contacts (≥50%) compared with infants and those aged 15–24 years. Face-to-face contacts fell by 88%, with the greatest falls occurring among children aged 1–14 years (>90%). Remote contacts more than doubled, increasing most in infants (over 2.5-fold). Total contacts for respiratory illnesses fell by 74% whereas contacts for common non-transmissible conditions shifted largely to remote contacts, mitigating the total fall (31%).

In conclusion, CYP’s contact with GPs fell, particularly for face-to-face assessments. This may be explained by a lower incidence of respiratory illnesses because of fewer social contacts; changing health-seeking behaviour; or a combination of both. The large shift to remote contacts mitigated total falls in contacts for some age groups and for common non-transmissible conditions.

The study can be read in the British Journal of General Practice.

Let patients self-refer to lifestyle management services

Recent draft guidance from NICE gives a much bigger role to exercise and weight loss in people with osteoarthritis, and painkillers such as paracetamol and strong opioids not advised.

I agree that the aims of the new draft NICE guidance on the management of osteoarthritis in primary care are good but the problem will be in providing patients with access to suitable lifestyle and exercise programmes. In many parts of England, these services are either not currently in place or have very limited capacity. As well as putting in place services with sufficient capacity, we also need to ensure there is equitable access to them, based on clinical need. We know from prior experience that it is more affluent and better educated patients who are more likely to take up these kind of lifestyle and exercise interventions.

We also need to simplify clinical pathways and allow patients to refer themselves directly to services without requiring a referral from a GP. This will improve the speed of access to these services for patients and reduce the demands on already over-stretched GP services.

A version of this blog was first published in the British Medical Journal.

Long term implications of Covid-19 in pregnancy

An article published in the BMJ by Allyah Abbas-Hanif, Neena Modi and myself discusses the long term implications of Covid-19 in pregnancy. Covid-19 in pregnancy increases the risk of severe complications for both mother and baby. The long term implications are unknown, but emerging signals warn of substantial public health threats. To counter high vaccine hesitancy in pregnancy we must end the default exclusion of pregnant women from the rigorous regulated drug development process and implement systematic, long term, population-wide surveillance of infected and non-infected people.

The full article can be read in the British Medical Journal.

The future of the Covid-19 pandemic in the UK – the essential role for vaccination

Thanks to Covid-19 vaccination, we have seen a substantial weakening of the link between Covid-19 infections and hospitalisations / deaths in the UK. But we don’t yet know how well this protection from serious illness and death will persist in the longer-term. We are also seeing “vaccine fatigue” set in with many people not keen on booster vaccines.

For the UK, the future challenges will include determining how frequently and in what groups Covid-19 booster vaccines are needed; ensuring a high take-up of vaccinations in all eligible groups; and having vaccines that are updated when necessary to protect against new variants. We have already had one additional booster vaccination programme in the UK this year; which targeted people 75 and over, residents of care homes, and people who are immunocompromised. A larger booster programme is planned for later this year that will target a wider range of people, including NHS staff.

Although some people are very optimistic about the future because of the recent decline in the number of Covid-19 cases, hospitalisations and deaths in the UK, this optimism does depend on maintaining high levels of Covid-19 immunity in the population. This won’t be easy and we will see some areas of the UK and some population groups with low take-up of booster vaccines. We therefore need to ensure that we have a strong vaccine delivery system in place that can work with local communities to ensure a high-take up of vaccination – particularly in the most clinically vulnerable groups at highest risk of serious illness and death.

Other Covid-19 control measures are also important and can be implemented when necessary, but ultimately it is vaccination that will allow UK society to function normally rather than these other measures.

Let’s keep cool about anxiety-inducing Monkeypox

Earlier this month, a case of Monkeypox was reported in London, followed by reports of further cases in the UK and in many other countries. Understandably, people are anxious whenever an outbreak of an unusual infectious disease occurs, likely more so because of their experiences during the Covid-19 pandemic. Although we need to take the disease seriously, Monkeypox is much less of a threat to global health than Covid-19 and won’t have the same impact on societies or lead to the type of control measures we have seen for Covid-19 over the past two years.

The virus that causes Monkeypox is found primarily in small animals, like rodents, in parts of West and Central Africa – but was first identified in monkeys (hence the name). It can sometimes spread to humans and because of international travel, then spread to other parts of the world. But unlike Covid-19, which is easily transmissible and has caused huge waves of infection globally, Monkeypox spreads much more slowly, requiring close contact with an infected person or animal to spread.

Monkeypox outbreaks can generally be contained through conventional public health measures – like identifying and isolating cases early on, tracing contacts to identify people who are at risk of infection, and good infection control practices when dealing with people who are infected. We know that smallpox vaccines also provides some protection against infection and can be used if necessary in health care workers or in close contacts to reduce their risk of becoming infected. However, use of vaccination will be very limited and we won’t see it used widely in the UK.

Our public health agencies are well-placed to manage the Monkeypox outbreak in the UK. We now have much more experience in areas such as contact tracing and in isolating people with infections than we did before the Covid-19 pandemic. Although we will continue to see cases of Monkeypox in the UK and elsewhere, our public health system has the capacity to limit the outbreak and prevent it from having a major effect on our society.

The Monkeypox outbreak does however reinforce the need for the UK to maintain a strong infection control system so that we are prepared to deal with this and any future infectious diseases that may enter the country. Finally, although people should not become unduly anxious and have a very low risk of coming into contact with a person who has Monkeypox, everyone should remain vigilant and seek medical advice if they become unwell and develop an unusual skin rash.

A version of this article was first published in the Evening Standard.

General practitioner perceptions of using virtual primary care during the COVID-19 pandemic

Whether it be a simple telephone call or more sophisticated video conferencing systems, virtual care tools have been in use in primary care settings worldwide in one form or another throughout the past two decades. Over time, these tools have grown in availability, matured in their capabilities, but played a largely supportive role as an alternative option to traditional face-to-face consultations. This all changed in early 2020 with the onset of the COVID_19 pandemic.

The COVID-19 pandemic presented a unique opportunity globally which put virtual care tools at the forefront of primary care delivery. The need for social distancing to limit disease transmission resulted in virtual care tools becoming the primary means with which to continue providing primary care services. Hence, our study’s goal was to capture the spectrum of GP experiences using virtual care tools during the initial months of the pandemic so as to better understand the perceived benefits and challenges, and explore what changes are needed to allow them to reach their fullest potential.

We carried out a global study to investigate this further, published in the journal PLOS Digital Health. We received 1,605 responses from 20 countries globally. Our results demonstrated that virtual care tools were beneficial in limiting COVID-19 transmission, improved convenience when communicating with patients, and encouraged the further adoption of virtual care tools in primary care. Challenges included patients’ preferences for face-to-face consultations, digital exclusion of certain populations, diagnostic challenges associated with the inability to perform physical examinations, and their general unsuitability for certain types of consultations. Practical challenges such as higher workloads, payment issues, and technical difficulties were also reported.

Learning from this global natural experiment is critical to both updating existing and introducing new health technology policies concerning virtual primary care. Doing so will be imperative to supporting and promoting the better use of these novel technologies in our evolving healthcare milieu.

DOI: https://doi.org/10.1371/journal.pdig.0000029