Month: November 2020

Vaccinating the UK against Covid-19

The global Covid-19 pandemic has led to over 50,000 deaths in the United Kingdom, disrupted health services for many other conditions, and has had enormous economic impacts that have led to massive increases in unemployment and government debt.[1,2,3] With the United Kingdom’s failure to implement an effective test, trace and isolate programme as we have seen in countries such as South Korea and New Zealand, a vaccination programme offers us the best way to finally bring this pandemic under control[4]. It is therefore essential that the Covid-19 vaccination programme is implemented well and that we do not repeat the many mistakes we have seen in the government’s response to Covid-19, such as in the Test and Trace programme.[5]

Primary care should be at the heart of the delivery of the UK’s vaccine programme. With around 7,000 general practices in England, for example, they are easy for patients to access and their staff are generally well-trusted by the public.  Unfortunately, a decade of under-investment in primary care has led to a shortage of general practitioners, very overstretched primary care teams, and reduced the ability of primary care to respond to new challenges.[6] These problems cannot be addressed quickly but the government can take some immediate actions to reduce pressures on primary care. This could include, for example, cutting the administrative burden on general practices by suspending appraisals, revalidation and CQC inspections for the foreseeable future.

To ensure smooth implementation of the vaccine programme, funding is required to pay for new vaccination centres, provide current general practice clinics with the facilities they need such as equipment for transporting and storing vaccines, and meeting the costs of administering a complex vaccination regime to patients who are housebound or living in care homes. Other required measures include funding to rapidly recruit additional staff such as general practitioners, nurses, healthcare assistants to administer vaccines; and staff to provide administrative and management support. It is also essential that primary care services for the management of acute and long-term problems, and preventive programmes such as children’s immunisations, continue to operate normally. This means that additional capacity rapidly needs to be created in primary care so that the vaccination programme does displace or delay other essential clinical work, particularly as Covid-19 vaccines are likely to take longer to administer than the other vaccines currently offered by the NHS, resulting in considerable extra work for primary care teams.

Moving on to the logistics of vaccine delivery, there are currently two types vaccines that are close to approval in the UK. Adenoviral vector vaccines such as ChAdOx1 nCoV-19 are logistically easier to deliver as they can be stored long-term in standard vaccines fridges and so could be administered by primary care teams working in the patient’s usual general practice.[7] In Contrast, mRNA vaccines have to be stored at very low temperatures (minus 70 degrees Celsius for the Pfizer / BioNTech mRNA vaccine) and have to be used within a short period of time after defrosting.[8] Hence, mRNA vaccines are more suitable for large vaccination centres with a high throughput of patients rather than the typical general practice. In the longer term, as more data on safety and efficacy becomes available, it would be appropriate to focus on a smaller number of vaccines, rather than continue with the government’s current approach of having many different vaccine options. As well as simplifying the vaccination programme, this would also cut its costs and reduce the likelihood or patients missing out on their second dose of vaccine because of its unavailability or receiving the wrong vaccine at their second appointment.

Looking forwards, we do not yet know how long the immunity and protection from infection generated by vaccination will last.[9] People may therefore require booster doses of vaccine at regular intervals and the NHS should also plan for this. This requires good call-recall systems, something which general practices can provide because of their computerised medical records and experience of delivering other vaccine programmes. We also need observational studies to assess how frequently “vaccine failures” occur (i.e. how many people contract Covid-19 despite being immunised and what their characteristics are), as well as data on adverse events and safety. The UK, with its system of computerised primary care records, is well placed to generate this data, particularly if linkages can be made to other data such as hospital episode statistics and mortality records. To do this, the problems that afflicted the Test and Trace programme in its early days, such as the failure to record test results in primary care records, must be avoided.[10] This is could be successfully achieved by integrating vaccination recording at the time of vaccination administration in the patient’s primary care record and not creating a separate information technology infrastructure as was done with Test and Trace.[11]

We need to ensure the NHS, and in particular primary care, is well-prepared for the programme and that unrealistic expectations of the timescale are not created amongst the public. The Covid-19 vaccination programme is too important to the health, wellbeing and economic security of the UK to delay its implementation or to get wrong.[12] The government has invested considerable funding into other areas of the Covid-19 response, including funding the private sector to deliver services such as Track and Trace. The funding that has been allocated to the NHS for the vaccination programme is currently small in comparison. Whatever investment is needed for the successful and timely delivery of the vaccination programme should be promptly provided by the government so the programme can begin at scale, rapidly vaccinate the at-risk population of the UK, and finally allow life in the UK to start to return to normal.

This article is based on an editorial published in the British Medical Journal

DOI: https://doi.org/10.1136/bmj.m4654

References

1. 50,000 COVID-19 deaths and rising. How Britain failed to stop the second wave. https://uk.reuters.com/article/health-coronavirus-britain-newwave/special-report-50000-covid-19-deaths-and-rising-how-britain-failed-to-stop-the-second-wave-idUSL8N2I94SG

2. Maringe C, Spicer J, Morris M, Purushotham A, Nolte E, Sullivan R, Rachet B, Aggarwal A. The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK: a national, population-based, modelling study. The Lancet Oncology. 2020 Aug 1;21(8):1023-34.

3. Office for Budget Responsibility. Economic and fiscal outlook – November 2020. https://obr.uk/efo/economic-and-fiscal-outlook-november-2020/

4. Majeed A, Seo Y, Heo K, Lee D. Can the UK emulate the South Korean approach to covid-19? BMJ 2020; 369 :m2084.

5. Scally G, Jacobson B, Abbasi K. The UK’s public health response to covid-19 BMJ 2020; 369 :m1932

6. Majeed A. Shortage of general practitioners in the NHS BMJ 2017; 358 :j3191

7. Ramasamy MN, Minassian AM, Ewer KJ, Flaxman AL, Folegatti PM, Owens DR, Voysey M, Aley PK, Angus B, Babbage G, Belij-Rammerstorfer S et al. Safety and immunogenicity of ChAdOx1 nCoV-19 vaccine administered in a prime-boost regimen in young and old adults (COV002): a single-blind, randomised, controlled, phase 2/3 trial. The Lancet. 2020 Nov 19.

8. Bower E. Which COVID-19 vaccines are lined up for roll-out on the NHS? https://www.gponline.com/covid-19-vaccines-lined-roll-out-nhs/article/1700217

9. Centers for Disease Control and Prevention. Frequently Asked Questions about COVID-19 Vaccination. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/faq.html

10. Carrell S, Garside J. Coronavirus testing hit by struggle to match results with NHS records  https://www.theguardian.com/world/2020/may/28/coronavirus-testing-hit-struggle-match-results-with-nhs-records.

11. Lind S. GPs may need to record Covid vaccinations on separate IT system, says NHS England. https://www.pulsetoday.co.uk/news/technology/gps-may-need-to-record-covid-vaccinations-on-separate-it-system-says-nhs-england/

12. Iacobucci G. Covid vaccine: GPs need more clarity on logistics and planning, say leaders BMJ 2020; 371 :m4555.

Was the government right to announce an easing of Covid-19 restrictions during Christmas?

  1. Was the government right to announce an easing of Covid-19 restrictions during Christmas?

When the current lockdown in England ends, it’s likely the government will introduce a new system of tiered restrictions. My view is that these restrictions should remain in place through the Christmas and New Year period, based on the local community infection rate. Easing the restrictions too quickly risks undoing all the gains we have made during the lockdown. Greater social mixing indoors over the Christmas and New Year holidays will inevitably lead to an increase in Covid-19 infections.

 

  1. Could allowing mixing of households actually mean people will die as a result?

Most person to person transmission of Covid-19 infection occurs within households. This is the rationale for the government’s policy of stopping different households from mixing with each other indoors. Allowing mixing of households indoors will inevitably lead to an increase in infections, which would be very serious for more vulnerable people, such as the elderly and those with major medical problems, who are at greatest risk of serious illness and death if they contract Covid-19.

 

  1. Won’t locking down during January make up for the Christmas easing?

We need sustainable measures to control Covid-19 rather than “stop-start” measures.

 

  1. Isn’t Christmas too important for people’s mental health and well-being to deny them the chance to celebrate it as normal?

Christmas is a very important part of our social fabric. We need to think how we can allow people to celebrate without risking their health and the health of more vulnerable people.

 

  1. Can’t we trust people to still be responsible and limit contact with their elderly relatives even if restrictions are eased?

Most people will be mindful about the health of elderly relatives and will take precautions to prevent them from falling ill even if restrictions are eased.

 

  1. If restrictions stay in place, won’t there be more risk of people rebelling against the rules and wilfully disobeying them?

There is a risk of that some people won’t follow the rules but the vast majority of people will be sensible and follow the local restrictions that are in place. With positive news about developments in vaccines, we may be able to live much more normally from around Easter onwards. It’s important we retain our discipline and follow rules for these next few months until sufficient people have been vaccinated against Covid-19, allowing a degree of “herd immunity” to develop, which will lead to lower infection rates.

 

  1. Would there be any risks involved in opening up churches for Christmas services?

Any indoor mixing poses risks and activities such as singing in indoor spaces have been shown to lead to increased risks of infection. It may be possible though to open churches in some parts of England where local infection rates are low and where good infection control measures – such as physical distancing and restricting the numbers who can enter a church – are followed.

 

  1. Won’t elderly people be getting vaccinated before Christmas anyway?

Although we have had positive news about vaccines recently, no vaccine is yet currently licensed for use in the UK. Assuming a vaccine can be rapidly licensed and is available for use from December onwards, we won’t have enough doses of the vaccines to have a major impact on the pandemic in 2020. All the current vaccines we have heard about require two doses a few weeks apart. It’s only when a large proportion of people have been fully immunised with two doses of vaccine will we see the effect of vaccination and this is likely to take a few months to achieve.

 

  1. Even if they allow us to have a big family Christmas, should we?

I would be cautious about large, indoor Christmas events – particularly if you have elderly relatives or relatives with serious medical problems.

 

  1. I want my whole family together at Christmas. What can I do to reduce the risks? (Should we self-isolate 2 weeks before? Take the kids out of school earlier etc. Is there anything we can do inside the house to reduce risk?)

Self-isolation can help but does not entirely eliminate the risk of infection. It’s not a good idea to disrupt children’s education by taking them out of school. Actions to reduce the risk indoors include avoiding overcrowding so that physical distancing can be maintained, ensuring that ventilation is good as the risk of infection is much higher in poorly ventilated spaces, and practising good hygiene, such as regular handwashing.

 

  1. Should we still get together for Christmas if the households have to travel from different parts of the UK to meet up?

It’s better to “stay local” if you can for Christmas. Once a vaccination programme is in place, this will allow a return to a more normal society; resulting in a much better Christmas experience for everyone next year in 2021.

Characteristics of children who are frequent users of emergency departments in England

Increasing pressures on emergency departments present a considerable challenge worldwide, particularly during winter. Before the COVID-19 pandemic, serious infectious disease incidence had fallen with the success of vaccination programmes. However, amidst the ongoing global pandemic pressure on hospital EDs are stretched to their limit. This can strain health resources and budgets and can result in poor clinical outcomes. Increasing demand for EDs may be driven by rising morbidity in an ageing population, poor access to primary care and increase in patient expectations. In England, in 2017/2018, there were 23.8 million  emergency department attendances, an increase of 22% since 2008/2009; rises were higher in the under-5 (28%–30%), and one-third of all British children visit an  emergency department each year. Such increases pose immense challenges to the National Health Service (NHS) amidst significant cuts in funding, given that that nearly half of the health budget is spent on emergency and acute care.

We conducted an observational study using routine administrative data. Hospital Episode Statistics (HES) data covering all attendances at NHS hospitals in England for the period April 2014–March 2017 were used. We published our study in the Emergency Medicine Journal We found that one in 11 children (9.1%) who attended an  emergency department attended four times or more in a year. Infants, boys and children living in more deprived areas had greater likelihood of being a frequent attender. We concluded that infants and children living in deprived areas have greater likelihood of being frequent attenders. Interventions that support parents and contribute to reducing avoidable emergency department attendance, particularly among infants, are crucial to provide appropriate support to users of emergency departments.

DOI: http://dx.doi.org/10.1136/emermed-2019-209122

COVID-19, seasonal influenza and measles: potential triple burden and the role of flu and MMR vaccines

Policy interventions aimed at reducing person-to-person transmission of SARS-CoV-2 (such as hand hygiene, physical distancing and wearing face coverings) were implemented globally to minimise healthcare burden, and to allow more time for an effective treatment and successful vaccine. After months of ‘lockdown’, many countries started to ease these measures recently only to see a surge in COVID-19 cases and deaths. During the winter of 2020–2021, we face the prospect of a dual burden of a COVID-19 pandemic and a seasonal influenza epidemic. However, what’s not being currently discussed is that the burden on healthcare could be further compounded by a potential surge of measles and rubella cases. This is due to: (1) a declining trend in Measles-Mumps-Rubella vaccine coverage accompanied by an increasing trend in Measles-Mumps-Rubella cases since 2016; and (2) disruption and suspension of Measles-Mumps-Rubella vaccination campaigns in 23 countries to cope with the COVID-19 pandemic. Our article was published in the Journal of the Royal Society of Medicine.

DOI: https://doi.org/10.1177%2F0141076820972668

Associations of Social Isolation with Anxiety and Depression During the Early COVID-19 Pandemic: A Survey of Older Adults in London

The COVID-19 pandemic is imposing a profound negative impact on the health and wellbeing of societies and individuals, worldwide. One concern is the effect of social isolation as a result of social distancing on the mental health of vulnerable populations, including older people. Our findings were published in the journal Frontiers in Psychiatry.

Within six weeks of lockdown, we initiated the CHARIOT COVID-19 Rapid Response Study, a bespoke survey of cognitively healthy older people living in London, to investigate the impact of COVID-19 and associated social isolation on mental and physical wellbeing. The sample was drawn from CHARIOT, a register of people over 50 who have consented to be contacted for aging related research. A total of 7,127 men and women (mean age=70.7 [SD=7.4]) participated in the baseline survey, May–July 2020. Participants were asked about changes to the 14 components of the Hospital Anxiety Depression scale (HADS) after lockdown was introduced in the UK, on 23rd March. A total of 12.8% of participants reported feeling worse on the depression components of HADS (7.8% men and 17.3% women) and 12.3% reported feeling worse on the anxiety components (7.8% men and 16.5% women). Fewer participants reported feeling improved (1.5% for depression and 4.9% for anxiety).

Women, younger participants, those single/widowed/divorced, reporting poor sleep, feelings of loneliness and who reported living alone were more likely to indicate feeling worse on both the depression and/or anxiety components of the HADS. There was a significant negative association between subjective loneliness and worsened components of both depression (OR 17.24, 95% CI 13.20, 22.50) and anxiety (OR 10.85, 95% CI 8.39, 14.03). Results may inform targeted interventions and help guide policy recommendations in reducing the effects of social isolation related to the pandemic, and beyond, on the mental health of older people.

DOI: https://doi.org/10.3389/fpsyt.2020.591120

Data-driven, integrated primary and secondary care for children: moving from policy to practice

Despite the best efforts of clinicians, traditional healthcare models often struggle to meet the increasingly complex needs of children and young people under the age of 18 years, as well as 21st century challenges such as obesity and mental health problems. Policy makers and clinical leaders have argued that greater integration of primary and secondary care has the potential to meet the ‘Quadruple aim’ of better population health outcomes, patient and family satisfaction, provider satisfaction and reduced costs. More integrated services and improved data sharing across organisations are key enablers of child health improvement. However, there is sparse literature on how more integrated care for children and young people might work in practice or contribute to achieving these goals. We present the experience of developing a new model for integrated care delivery for children and young people in North West London, based on a common system of clinical records or dashboards across all providers. It includes case studies that illustrate the development of strong relationships and shared learning experiences between primary and secondary care. The article was published in the Journal of the Royal Society of Medicine.

DOI: https://doi.org/10.1177%2F0141076820968781

The failure of England’s Test and Trace system means we will be in and out of lockdowns for some time

Whether we will come of the 4-week lockdown on schedule will depend on how low the government’s Covid-19 strategy brings the R-value for the country. The R value is the average number of people that each new case of Covid-19 infects. If the R value for England is less than one, the daily number of cases will start to fall; and if the R value is greater than one, the daily number of cases will continue to increase. Once the R value is below one, and the daily number of cases start to fall, the number of people being admitted to hospital and the number of deaths will also start to fall.

There is though a lag before the number of hospital admissions and deaths begin to fall. This is because it can take 1-2 weeks from becoming infected before a person is unwell enough to need hospital treatment. There is then as further period of time before death. Hence, case numbers start to fall first, followed by the number of people admitted to hospital and then finally, the number of people dying from Covid=19.

The “nightmare scenario” that we will face is that the new lockdown measures are not strict enough or people do not comply with them, meaning that the R value stays above one and the numbers of cases, hospital admissions and deaths do not fall. This will mean continuing restrictions after the 4-week lockdown period ends. Even if the number of Covid-19 cases does fall to a more manageable level by the end of the lockdown, there will still be ongoing restrictions on social activities, resulting in Christmas 2020 being very different from a normal Christmas.

It’s also possible that we will see future waves of Covid-19 infection after lockdown measures are relaxed – as we saw earlier in the year – meaning that we may get further lockdowns followed by periods of relaxation of lockdown measures. Unfortunately, ever since the start of the pandemic, England’s Test and Trace system has not worked well enough to suppress local outbreaks promptly and keep the number of cases low – as we have seen in countries such as New Zealand, Taiwan and South Korea.

Hence, this cycle of lockdowns and restrictions of activities, followed by some loosening of these restrictions, may not end until we have a safe and effective vaccine that can finally bring Covid-19 under control in England and across the rest of the world. The encouraging news is that the early results about the safety and effectiveness of the new vaccines being developed for Covid-19 are very positive; and we may be able to launch a large-scale vaccine programme in the United Kingdom very soon. This vaccine programme is going to be complex and challenging to deliver but the NHS does have the expertise to do this.

Preliminary Outcomes of a Digital Therapeutic Intervention for Smoking Cessation in Adult Smokers: Randomized Controlled Trial

Tobacco smoking remains the leading cause of preventable death and disease worldwide. Digital interventions delivered through smartphones offer a promising alternative to traditional methods, but little is known about their effectiveness. Our objective was to test the preliminary effectiveness of Quit Genius, a novel digital therapeutic intervention for smoking cessation. Our research was published in the journal JMIR Mental Health.

We used a 2-arm, single-blinded, parallel-group randomized controlled trial design. Participants were recruited via referrals from primary care practices and social media advertisements in the United Kingdom. A total of 556 adult smokers (aged 18 years or older) smoking at least 5 cigarettes a day for the past year were recruited. Of these, 530 were included for the final analysis. Participants were randomized to one of 2 interventions. Treatment consisted of a digital therapeutic intervention for smoking cessation consisting of a smartphone app delivering cognitive behavioral therapy content, one-to-one coaching, craving tools, and tracking capabilities. The control intervention was very brief advice along the Ask, Advise, Act model. All participants were offered nicotine replacement therapy for 3 months. Participants in a random half of each arm were pseudorandomly assigned a carbon monoxide device for biochemical verification. Outcomes were self-reported via phone or online. The primary outcome was self-reported 7-day point prevalence abstinence at 4 weeks post quit date.

556 participants were randomized (treatment: n=277; control: n=279). The intention-to-treat analysis included 530 participants (n=265 in each arm; 11 excluded for randomization before trial registration and 15 for protocol violations at baseline visit). By the quit date (an average of 16 days after randomization), 89.1% (236/265) of those in the treatment arm were still actively engaged. At the time of the primary outcome, 74.0% (196/265) of participants were still engaging with the app. At 4 weeks post quit date, 44.5% (118/265) of participants in the treatment arm had not smoked in the preceding 7 days compared with 28.7% (76/265) in the control group (risk ratio 1.55, 95% CI 1.23-1.96; P<.001; intention-to-treat, n=530). Self-reported 7-day abstinence agreed with carbon monoxide measurement (carbon monoxide <10 ppm) in 96% of cases (80/83) where carbon monoxide readings were available. No harmful effects of the intervention were observed.

We concluded that the Quit Genius digital therapeutic intervention is a superior treatment in achieving smoking cessation 4 weeks post quit date compared with very brief advice.

DOI: https://doi.org/10.2196/22833

Impact of Remote Consultations on Antibiotic Prescribing in Primary Health Care: Systematic Review

here has been growing international interest in performing remote consultations in primary care, particularly amidst the current COVID-19 pandemic. Despite this, the evidence surrounding the safety of remote consultations is inconclusive. The appropriateness of antibiotic prescribing in remote consultations is an important aspect of patient safety that needs to be addressed. We aimed to summarize evidence on the impact of remote consultation in primary care with regard to antibiotic prescribing. The research was published in the Journal of Medical Internet Research.

In total, 12 studies were identified. Of these, 4 studies reported higher antibiotic-prescribing rates, 5 studies reported lower antibiotic-prescribing rates, and 3 studies reported similar antibiotic-prescribing rates in remote consultations compared with face-to-face consultations. Guideline-concordant prescribing was not significantly different between remote and face-to-face consultations for patients with sinusitis, but conflicting results were found for patients with acute respiratory infections. Mixed evidence was found for follow-up visit rates after remote and face-to-face consultations.

We concluded that there is insufficient evidence to confidently conclude that remote consulting has a significant impact on antibiotic prescribing in primary care. However, studies indicating higher prescribing rates in remote consultations than in face-to-face consultations are a concern. Further well-conducted studies are needed to inform safe and appropriate implementation of remote consulting to ensure that there is no unintended impact on antimicrobial resistance.

DOI: https://doi.org/10.2196/23482