Month: December 2020

The NHS must be fully supported in rolling out the Covid-19 vaccination programme

The news today that the MHRA has approved the AstraZeneca adenoviral ChAdOx1 nCoV-190 vaccine for use in the UK is excellent news for the Covid-19 vaccination programme. The results of the vaccine trial published in the Lancet earlier in December were encouraging, even if the overall efficacy of 70% was lower than the 90-95% being reported for mRNA vaccines from Pfizer-BioNTech and Moderna. The vaccine still prevented serious cases of illness amongst the recipients.

The AstraZeneca vaccine is cheaper than the mRNA vaccines and can be stored in a conventional vaccine fridge. Hence, it is an easier vaccine to use in primary care and community settings, including in low and middle income countries. The most commonly reported adverse reactions from the vaccine were fatigue, headache, feverishness, and myalgia. More serious adverse events were rare and not believed to be directly related to the vaccine.

One caveat for all the Covid-19 vaccines is that we don’t yet know how long the immunity they generate will last. We also don’t yet know if they stop people being infectious. As more data becomes available, we will be able to better answer these important two questions.

Now that the AstraZeneca vaccine has been approved by the MHRA, we need to see it rapidly rolled out by the NHS. The vaccine is highly suited for use in UK primary care as it can be stored in the standard vaccine fridge found in all general practices; and given to patients either opportunistically when they attend for an appointment for another problem or in dedicated vaccination clinics. It can also be much more easily used for people living in care homes and for housebound patients than the mRNA vaccines.

To ensure successful delivery of the vaccination programme, it’s essential that primary care teams and general practices are given all the support they need for the Covid-19 vaccination programme. Now is not the time for penny-pinching or for repeating the many mistakes made in the other parts of the government’s Covnd-19 strategy. We also need the government to be transparent about the amount of vaccine available for use now. Although the government has ordered 100 million doses of the vaccine (enough for all adults in the UK), we need the government to be clear what the timescale is for delivering the vaccine to the NHS and how much vaccine the NHS will be supplied with during the crucial month of January.

Vaccination offers the UK the only way out of the Covid-19 pandemic. Rapid delivery of vaccines to target groups and a high uptake of vaccination amongst the public are essential if we are to start to return life in the UK to normal.

Vitamin D supplementation for the prevention and treatment of Covid-19

During the Covid-19 pandemic, various treatments and management strategies are being examined to see if they can either help prevent Covid-19 or improve outcomes once people are infected. There are suggestions from some studies that Vitamin D could improve outcomes in people with Covid-19. The National Institute for Health and Care Excellence (NICE) recently assessed assess the role of Vitamin D in Covid-19.

In its evidence review, NICE concluded that there was currently insufficient evidence to recommend Vitamin D for the prevention and treatment of Covid-19. NICE did recommend, however, that people in the UK should follow government guidance on taking Vitamin D supplements; particularly people from groups at higher risk of Vitamin D deficiency.

The panel also conclude that there was a need for further research on Vitamin D supplementation for preventing and treating Covid-19. Larger prospective studies with sufficient power to look at key outcomes, and also to examine outcomes in subgroups such as the elderly and people from ethnic minorities, are needed.

The bottom line is therefore there is currently insufficient data to recommend Vitamin D supplements for the treatment of Covid-19 but irrespective of this, people should still consider taking Vitamin D supplements, particularly if they are in a high risk group for Vitamin D deficiency. We await the results of larger studies with more rigorous designs.

How to cut Christmas Day coronavirus risk – from presents to games and dinner

In a Daily Mirror article published on Christmas Eve, Matt Roper and I discuss ways to stay safe this Christmas when the UK is in the midst of a pandemic, with Covid-19 cases rising across the country. The key action is to minimise mixing indoors with people from other households. Think carefully before you socialise, particularly if this will be with people at higher risk of death and complications from Covid-19, such as the elderly and those with long term health problems.

How often should we wash or sanitise our hands?

You should aim to get into a routine for handwashing. I would recommend handwashing around every two hours during the daytime. You should also wash your hands before and after any activity that might increase the risk of infection, such as handling food or when you have been in contact with other people. Using soap and water is fine, and there is no need to use expensive hand sanitiser unless soap and water are not readily available.

Should we keep the windows open? What if it gets too cold?

The risk of infection is substantially higher in poorly ventilated, indoor spaces. Good ventilation helps ensure that any virus that is in the air is dispersed more quickly, thereby reducing the risk of infection, if you are indoors with people who are not from your household. If you are not able to keep the room at a reasonable temperature whilst also maintaining good ventilation, you should consider whether it is safe for you to meet indoors with people from other households.

How long should relatives stay for? (i.e., just a few hours, overnight, a few days? Does it really matter how long?)

Whether people can stay with you depends on the local rules for your area. In England, mixing with people from other households is not allowed indoors if your live in a Tier 3 or Tier 4 area, except on Christmas Day (but not in Tier 4 areas). Most person-to-person transmission of Covid-19 takes places within households. Hence, where visits are allowed, these should be kept to a minimum period and overnight stays should be avoided. The longer you spend indoors with other people and the more people you mix with, the greater is the risk of transmission of infection.

What about Christmas presents/cards? Should they be wiped down first?

The risk of infection from handling presents and cards will not be great, but it is still a good idea to wipe them down first and leave them for a few hours before opening them. Remember to wash your hands after handling objects that have been touched by other people.

How close can we get? (i.e., should we hug, sit on the same sofa, be together in the kitchen etc…)

Direct physical contact with other people through, for example, hugging or shaking hands, increases the likelihood that the Coronavirus (SARS-CoV-2) will transfer between people and will therefore increase the risk of infection. Wherever possible, social distancing should be maintained (two metres ideally, one metre as an absolute minimum). In practice, this will be difficult for many people indoors, which is why indoor mixing with people from other households increases the risk of infection. Do not meet people from other households if you have any symptoms of a possible Covid-19 infection or if you are within 10 days of contact with somebody who has had an infection.

Is it better for younger family members to visit older ones, or for older ones to come to see younger ones?

It doesn’t really matter which way around the visit is; any mixing of people from different households will increase the risk of infection. Choose the location where you can maintain the best infection control measures; for example, a house with larger rooms and good ventilation rather than a small flat. Remember to follow the local rules on household mixing for your area; and practise good infection control, such as social distancing and regular hand-washing. Meeting outdoors is always safter than meeting indoors as any virus that is in the air will disperse much more quickly.

Are there any Christmas tradition we shouldn’t do? (i.e., Mistletoe, charades, board games, carol singing…?)

It’s best to avoid handling objects that have been touched by other people. Activities such as singing indoors have also been shown to increase the risk of infection as they are what are known as “aerosol generating”. Although Christmas is a special time and an important part of our social fabric, special precautions are needed this year and for the first few months of 2021. We need to maintain these measures until such time as the NHS Covid-19 vaccination programme starts to protect us and bring infection rates down.

How should the seating for people from different households be arranged for Christmas dinner?

People from different households should ideally maintain adequate social distancing wherever possible. Good ventilation helps to disperse any virus in the air more quickly.

Which is the safest way to serve the food? (i.e., Plated up in the kitchen rather than served from the table etc?).

It’s better to plate food in the kitchen rather than from the table or using shared platters. If food is served from a table, it is more likely to become contaminated.

Is there any kind of food we shouldn’t have? (Shared bowls of nuts, buffet style food, too much alcohol etc?)

Shared dining has been shown to increase the risk of infection. Hence, shared food such as bowls of nuts or buffet style food is best-avoided as handling food by many people will increase the risk of infection (not just for Coronavirus but also for gastroenteritis). Avoid drinking too much and remain aware of your surroundings and of other people around you.

What extra hygiene measures should be taken?

The best measure you can take is to meet outdoors where the risk of infection is much lower than indoors. If meeting indoors, ensure that surfaces are cleaned, ventilation is good, and anyone who is unwell or has had recent contact with someone with a Covid-19 infection stays at home and does not mix with other people. Take particular care with hygiene in higher risk areas such as kitchens and bathrooms. If you are in a high-risk group for a more severe Covid-19 illness or death, you need to take additional precautions and consider whether it is safe for you to meet people from other households indoors. You will eventually be offered a Covid-19 vaccine and once vaccine coverage in the population is high, we will see a decline in infection rates, making it safer for everyone to start to resume normal social activities.

Covid-19 in London

The Covid-19 situation in London is now very serious, with the number of Covid-19 cases doubling in the past to week to around 50,000. Infection rates are highest in the North-East of London, with increases seen all across the city.

The number of hospital patients with Covid-19 has increased to around 3,000 compared with around 1,600 one month ago. The number of patients requiring ventilators has increased by 100 over the last week to around 360. There are also pressures on other parts of the NHS, such as GP, mental health, and community services.

The new strain of SARS-CoV-2 is now becoming the most commonly identified strain in London and the South-East of England. It appears to be more infectious than other strains, and this will drive up the number of cases, people requiring hospital treatment and deaths.

The latest statistics show how rapidly the situation can change. From a period around one month ago, when case numbers were falling and NHS pressures were sustainable, we are now on a trajectory of rapidly increasing cases, hospital admissions and deaths in London.

Urgent action is needed to control the Covid-19 pandemic on London, protect its population and reduce pressure on the NHS. This requires everyone to strictly follow the local Tier 4 rules. In particular, mixing indoors with people from other households should be avoided.

Most transmission of infection occurs indoors and it is stopping mixing of people from different households in indoor settings that is the key to breaking chains of infection. Other measures, such as wearing face masks in public spaces and good hygiene, are also essential.

We do now have one vaccine for Covid-19 licensed for use in the UK. We urgently need other vaccines to be approved for use; along with a massive increase in supply of vaccines and mobilisation of the NHS to deliver vaccines to the population on a speed and scale not previously seen in the UK.

Table: London boroughs by highest number of COVID-19 positives per 100k population.7–day rolling rate by specimen date – ending Dec 17. The table is from @UKCovid19Stats.

What are the priorities for the NHS during the period when tight Covid-19 restrictions are in place?

People in many areas of the United Kingdom will be living under tight Covid-19 restrictions for the next few months. In London and the South-East of England, for example, this means being placed under Tier 4 restrictions.

For the NHS, there will be two main priorities during this period. The first will be to rapidly implement the Covid-19 vaccination programme. This is our best hope of bringing the pandemic under control and allowing life to start to return to normal. But success requires working on a speed and scale not seen before for any public health programme in the United Kingdom. Adequate supplies of vaccine must be secured and the infrastructure put in place to administer vaccines rapidly to tens of millions of people.

The second priority will be to ensure that people with non-Covid illnesses receive the care they need. This will be very challenging in the middle of a pandemic. We have already seen a large backlog of NHS work build up in 2020. The NHS must ensure that people receive the healthcare they need at this difficult time; whether this is in general practice, mental health, or hospital settings to prevent a rise in ill-health and deaths from non-Covid related causes.

London and South-East England Move to Tier 4 Restrictions

After a period from mid to late November in which the number of people with a positive Covid-19 test in the UK declined, in recent weeks we have unfortunately seen a rise in Covid-19 cases, with over 28,000 cases reported in the UK on 18 December. This rise in case numbers has been particularly high in parts of London and South-East England, leading today to these areas being placed into a new Tier 4 Level. Infection rates are also increasing in other parts of the UK, such as Wales, leading to increased pressure on the NHS.

Despite the enthusiasm and optimism generated by the Covid-19 vaccination programme, the number of people being vaccinated is well-below the level needed to start to reduce infection rates in the community. Without a very rapid escalation in the Covid-19 vaccination programme, which in turn depends on further vaccines being licensed for use in the UK and very quickly obtaining a much large supply of vaccines than we have available now, it will be sometime (perhaps several months, depending on vaccine availability) before enough people in England and elsewhere in the UK are vaccinated to have an impact on Covid-19 infection rates.

Our current crisis will require mass vaccination on a speed and scale we have not seen before in the UK. This needs to target older people, those with long-term health problems, and key workers in the first instance (NHS staff, care workers, and teachers for example); before moving on to other groups.

For the time being, it’s essential that people follow the local Covid-19 rules for the area where they live. In particular, mixing indoors with people from other households should be avoided as the risk of infection in substantially higher in crowded, indoor spaces where ventilation is poor.

Everyone should be mindful of older friends, relatives, and social contacts; and those with long-term medical problems. These groups are at the highest risk of serious illness and death if they contract Covid-19; and anybody in one of these groups should be very cautious in their interactions indoors with people not from their immediate household.

Although everyone wants to enjoy Christmas, it’s essential that infection control measures and local Covid-19 rules are followed during the holidays to protect yourself and others, and to relieve pressure on the NHS. Please also attend for your Covid-19 vaccination when you are invited. Achieving a high vaccine coverage rapidly is our best way to bring the Covid-19 pandemic under control.

Changes in Covid-19 Tiers in England

After a period from Mid-November onwards in which the number of people with a positive Covid-19 test in the UK declined, in recent days we have unfortunately seen a rise in Covid-19 cases, with over 25,000 cases reported in the UK on 16 December. This rise in case numbers has been particularly high in parts of London and South-East England, leading to more areas of England being placed in Tier 3.

Despite the enthusiasm and optimism generated by the Covid-19 vaccination programme, the number of people being vaccinated is well-below the level needed to start to reduce infection rates in the community. Without a very rapid escalation in the Covid-19 vaccination programme, which in turn depends on very quickly obtaining a much large supply of vaccines than we have available now, it will be sometime (perhaps several months, depending on vaccine availability) before enough people in England and elsewhere in the UK are vaccinated to have an impact on Covid-19 infection rates.

For the time being, therefore, it’s essential that people follow the local Covid-19 rules for the area where they live. In particular, mixing indoors with people from other households should be avoided as the risk of infection in substantially higher in crowded, indoor spaces where ventilation is poor.

Everyone should be mindful of older friends, relatives and social contacts; and those with long-term medical problems. These groups are at the highest risk of serious illness and death if they contract Covid-19 and should be very cautious in their interactions indoors with people not from their immediate household.

Although everyone wants to enjoy Christmas, it’s essential that infection control measures and local Covid-19 rules are followed during the holidays to protect yourself and others, and to relieve pressure on the NHS.

Measuring the long-term safety and efficacy of Covid-19 vaccines

The news that two UK recipients of the Covid-19 Pfizer-BioNTech mRNA vaccine suffered allergic reactions illustrates the need for accurate recording of any adverse events following administration of Covid-19 vaccines. As these vaccines are new, we don’t yet have long-term data on their safety and efficacy. This data is essential to help build public confidence in these vaccines and ensure take-up of the vaccines is high; not just in the UK but globally as well. The data will also help identify how frequently vaccination is needed to ensure vaccine recipients retain their immunity to Covid-19.

The UK is well-placed to collect this data. We have a National Health Service that has developed computerised medical records for use in general practices on a population of around 67 million people. These electronic medical records provide longitudinal data on people’s health and medical experiences. They can now also be linked to other data; such as hospital admissions records and mortality records, as well as to the results of Covid-19 tests, increasing their value for monitoring the safety and efficacy of the new Covid-19 vaccines.

The comprehensive nature of these medical records and the large population they cover mean that they can be used to look at safety and efficacy of Covid-19 vaccines in specific populations. This could be, for example, by age, sex, medical history or ethnic group. It would also be possible to look at more serious health outcomes and death rates by linkage to other data sets. Hence, planning how we would use these data is essential and needs to start now.

The use of these data will be facilitated by the recently developed clinical codes for Covid-19 vaccines for recording information in electronic medical records. These codes include, for example, codes for whether people attended or did not attend for their vaccination appointment; whether they declined to be vaccinated; and whether they had a clinical contra-indication to being vaccinated. Other codes allow recording of the specific vaccine that was administered, which will be essential for comparing the long-term safety and efficacy of different Covid-19 vaccines.

The data from electronic medical records can be supplemented by the reporting of any suspected adverse events by health professionals to the MHRA via the Yellow Card Scheme. Vaccine recipients should also be encouraged to report any reactions directly to the MHRA a well as to their doctor. This allows the MHRA to build up information on the safety profile of the new Covid-19 vaccines and advise patients and the public of any potential problems.

Curbing the spread of COVID-19 in low income countries

Globalisation impacts the epidemiology of communicable diseases, threatening human health and survival globally. The ability of coronaviruses to spread, quickly and quietly, was exhibited with Severe Acute Respiratory Syndrome in 2002–2003 and, more recently, with COVID-19. Not sparing any continent, the World Health Organization declared a COVID-19 pandemic on 11 March 2020. In an article published in the Journal of Royal Society of Medicine, we discussed how higher income countries can support the response to Covid-19 in low income countries.

Despite high-income countries being inordinately impacted, due to the increasing number of COVID-19 cases, SARS-CoV-2 continues to represent a looming threat to the Global South, leading the World Health Organization to previously state that ‘Our biggest concern continues to be the potential for COVID-19 to spread in countries with weaker health systems’ and that Africa could become the next epicentre.

However, while academics, public health experts and macroeconomists discuss among themselves, using collaborative strategies to reduce morbidity, mortality and economic devastation, these discussions have not involved low- and middle-income countries. COVID-19 may cause unprecedented humanitarian health needs in countries already subjected to unaffordable, fragmented and fragile health systems; as COVID-19 unfolds a worldwide economic crisis, with the poor and other vulnerable groups affected disproportionately, building health system resilience, through an urgent and coordinated global response, that allocates resources and funds efficiently, must be prioritised in this dynamic and shifting pandemic.

DOI: https://doi.org/10.1177/0141076820974994

Effectiveness of mental health workers colocated within primary care

Mental health disorders contribute significantly to the global burden of disease and lead to extensive strain on health systems. The integration of mental health workers into primary care has been proposed as one possible solution, but evidence of clinical and cost effectiveness of this approach is unclear. In a paper published in the journal BMJ Open, we reviewed the clinical and cost effectiveness of mental health workers colocated within primary care practices.

Fifteen studies from four countries were included. Mental health worker integration was associated with mental health benefits to varied populations, including minority groups and those with comorbid chronic diseases. The interventions were correlated with high patient satisfaction and increases in specialist mental health referrals among minority populations. However, there was insufficient evidence to suggest clinical outcomes were significantly different from usual general practitioner care.

We concluded that while there appear to be some benefits associated with mental health worker integration in primary care practices, we found insufficient evidence to conclude that an onsite primary care mental health worker is significantly more clinically or cost effective when compared with usual general practitioner care. There should therefore be an increased emphasis on generating new evidence from clinical trials to better understand the benefits and effectiveness of mental health workers colocated within primary care practices.

DOI: http://dx.doi.org/10.1136/bmjopen-2020-042052