Author: Azeem Majeed

I am Professor of Primary Care and Public Health, and Head of the Department of Primary Care & Public Health at Imperial College London. I am also involved in postgraduate education and training in both general practice and public health, and I am the Course Director of the Imperial College Master of Public Health (MPH) programme.

Healthier schools during the COVID-19 pandemic: ventilation, testing and vaccination

In an article published in the Journal of the Royal Society of Medicine, we discuss how the UK can make its schools more Covid-secure. We were very grateful that Louise Voden, Head Teacher of the Nower Hill High School in Middlesex was able to contribute to the paper as a co-author.

Children are more likely than adults to have a mild or asymptomatic infection; hence, Covid-19 infection often goes undetected in children. When symptomatic, children shed the virus in similar quantities to adults and can infect others but it is unclear how infectious children with asymptomatic infections are. Large outbreaks of Covid-19 in schools have not been frequently reported but this may be because school outbreaks are rarely investigated in detail; for example, through the use of mass testing when after a case has been detected in a child, to determine the true infection rate among children in the school.

To keep schools open, there is an urgent need to implement more effective on-site mitigation strategies – with particular attention to ventilation and testing. In addition, it is essential that teachers and other school staff should be added to the priority list for vaccination. As far as ventilation is concerned, we suggest undertaking a feasibility study of implementing better ventilation and filtration systems in schools as well as some pilot work and research involving indoor air quality experts. Until then, keeping doors and windows open – for as much as is reasonably practicable – seems to be the best way forward.

Regarding Covid-19 tests, there is an urgent need to develop an appropriate guideline for schools on how staff and students should be tested regularly to work towards Covid-mitigated environment in schools. The recommendations on ventilation, testing and vaccination need to be combined with other infection control measures, such as wearing face masks or face coverings for staff and older students, regular cleaning of surfaces and frequent handwashing.

A failure to implement adequate control measures could result in Covid-19 outbreaks in schools then extending to the wider community, which would be a threat to public health, particularly for more vulnerable people such as the elderly, as well as leading to harm to children and families from school closures.

DOI: https://doi.org/10.1177/0141076821992449

COVID-19 Vaccination in the UK: We Need a Sustainable Infrastructure for the Programme

Earlier during the week starting on 15 February, we learned that more than 15 million people in the UK have now received their first dose of a COVID-19 vaccine, including more than 90% of people aged 75 and over. All residents of care homes have also now been offered a vaccination. This is excellent news and means that the groups that for the vast majority of COVID-19 deaths have now been immunised.

We will start to see the effects of vaccination in the coming weeks once enough time has elapsed for people to develop post-vaccination immunity. In particular, this should result in a reduced burden on the NHS as well as a lower death rate. But although we can be proud about what the vaccination achieved, we also need to remember that the programme is a marathon and not a sprint. There is a lot more work to do yet to complete the programme.

As well as continuing to offer first doses of vaccine to people, in April we will need to start offering the delayed second doses of vaccine, which will substantially increase the workload generated by the vaccination programme and place greater demands on NHS vaccination teams. We have also thus far been vaccinating the groups where “vaccine hesitancy” is generally low, such as the elderly and health professionals. As the figure below shows, from the UK Office for National Staistics, we will now start to vaccinate younger people, among whom vaccine hesitancy is at a much higher level than among older people.

Vaccine hestitancy is also more common in Black and other minority ethnic groups, as shown below, in a figure also from the UK Office for National Statistics. These groups are at higher risk of infection, severe disease and death. Hence, it is essential that vaccine hesitancy is also addressed in ethnic minority groups through sustained engagement with communities.

It’s also possible that people will need additional “booster” doses of vaccine at some point to counteract the effects of decreasing vaccine-generated immunity and to deal with new variants of SARS-CoV-2 amongst which current vaccines may be less effective. To help develop these modified vaccines, we will need continued research and it’s essential that members of the public sign up to take part in these projects; in particular, older people and people from ethnic minority groups, both of whom are often under-represented in trials.

We have made great progress in developing vaccines and implementing a vaccination programme. Congratulations to all for this; including industry, universities, government, the NHS and the public. But we are only at the start of this programme. We will need a sustainable, long-term vaccine infrastructure that will require investment and staffing, as well as continuing to update our vaccines to deal with new variants of SARS-CoV-2 if current vaccines are not fully effective against them.

THIS ARTICLE WAS UPDATED ON 17 FEBRUARY 2021: Over 15 million people in the UK have now received at least one dose of Covid-19 vaccine. The challenge will be to maintain this pace when we start giving second doses of vaccine to this group later in March, whilst also giving other target groups their first dose.

Your Covid-19 vaccine questions answered

My gran has had both her jabs. Once lockdown has ended, can I go and see her?

Once lockdown ends and the prohibition on people from different households mixing indoors stops, including for the clinically extremely vulnerable, you would be able to visit your grandmother. However, it may be some time before this happens.

I’ve been shielding on my own. Once I’ve had the vaccine will I be able to form a bubble with other family members?

You would need to continue to follow any lockdown rules that are in place in your local area even after you have had two doses of the vaccine.

I’ve had my first vaccine – can I hug my grandchildren?

One vaccination offers only partial protection. Two vaccinations are needed for maximum protection. Even after receiving two doses of vaccine, you would still need to follow any lockdown rules that were in place in your local area.

Can my employer force me to get vaccinated?

It’s unlikely that employers could force you to get vaccinated but they could recommend vaccination for staff who have public-facing roles that place them at increased risk of infection.

Everyone in my mum’s care home has had the vaccine. Should they allow relatives to visit without a screen?

Relatives will continue to need to be screened for now because the Covid-19 vaccines are not 100% effective even after two doses and some vaccinated people can still get infected. The risk of serious illness, complications and death is very high in people living in care homes and we have to be particularly cautious with this group.

Can I still be fined for breaking the rules if I show my vaccine card?

A vaccine card does not exempt you from following any local or national rules that are in place; so yes, you can be fined for breaking lockdown rules even if you have proof of vaccination.

Once everyone has been vaccinated, might there be places those who have refused the vaccine aren’t allowed?

It’s possible that some places might implement this policy. For example, some cruise companies have said they will require proof of vaccination from customers.

Will I need to show proof of my vaccine to travel abroad?

It’s possible that some countries will require proof of vaccination before allowing you to travel there but this will vary from country to country.

If I’ve had my vaccine will I still have to self-isolate if I’ve been in contact with someone who tested positive?

If you have been in recent contact with someone who has tested positive, you would still need to self-isolate for 10 days because at this point, we don’t know if vaccination stops you being infectious.

When will we know if the vaccine just stops you getting symptoms or stops you actually getting infected?

It will take some time for research to establish this. We may find out later in 2021.

If one of my employees has been vaccinated, should I consider him/her for a role that has a higher risk of infection?

Employers should risk assess staff before placing them in a specific role. My view is that vaccination should not be used as a reason for placing potentially clinically vulnerable staff in high-risk roles that expose them to a greater risk of infection.

I’m a piano teacher. Can I advertise for students using my proof of vaccination to show I’m Covid free?

Vaccination does not guarantee that you will be “Covid-free”. You would need to continue to follow any lockdown rules that are in place in your local area.

My Medical and Public Health Wish List for 2021

2020 was a difficult year for many people all over the world (if only we had the benefit 20-20 hindsight at the start of the year). Here is a list of 10 developments I would like to see in 2021.

1. A much better government response to the Covid-19 pandemic with interventions introduced at the right time and correct scale.
2. A rapid rollout of the Covid-19 vaccination programme so that target groups such as older people, those with long-term health problems, NHS staff and other key workers such as teachers and people working in high-risk occupations can be protected.
3. Awareness that the Covid-19 pandemic must be ended globally, not just in richer countries, and ensuring that people across the globe have access to the vaccines that will be introduced in 2021.
4. Better government policies to address key health challenges and risk factors for poor health such as poor diets, lack of exercise, and obesity; along with the wider determinants of health such as housing, education, poverty, and employment.
5. Greater support for our schools and teachers who have been outstanding in 2020 in trying to keep children educated during the midst of a global pandemic.
6. Respect for science and a reduction in the anti-science conspiracy theories that are some common on social media and in everyday conversations.
7. Greater support and recognition of the role played by primary care in ensuring good access to healthcare and improved health outcomes globally.
8. A positive relationship with our European neighbours and with the European Union.
9. An adequate replacement for the ERASMUS programme so that or students can benefit from the social, cultural and education opportunities that placements at universities in other European countries can bring.
10. An improvement in the IT systems that staff working in the NHS have to use. Poor IT leads to high levels of stress among NHS staff, and wastes valuable time and money that could be used to better effect elsewhere.

This is just a small list. Let me know what’s on your wish list for 2021.

Returning to physical activity after a Covid-19 infection

In an article published in the British Medical Journal, we discuss returning to physical activity after a Covid-19 infection. A risk-stratification approach can help maximise safety and mitigate risks, and several factors need to be taken into account. First, is the person physically ready to return to activity? In the natural course of Covid-19, deterioration signifying severe infection often occurs at around a week from symptom onset. Therefore, consensus agreement is that a return to exercise or sporting activity should only occur after an asymptomatic period of at least seven days, and it would be pragmatic to apply this to any strenuous physical activity. English and Scottish Institute of Sport guidance suggests that, before re-initiation of sport for athletes, activities of daily living should be easily achievable and the person able to walk 500 metres on the flat without feeling excessive fatigue or breathlessness. However, we recommend considering the person’s pre-illness baseline, and tailoring guidance accordingly.

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.