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.

Why should I other getting a Covid-19 vaccine booster?

I have much bigger healthcare concerns than getting COVID-19, and the NHS doesn’t help me with them. Why should I bother to help them by getting this vaccine?

This is a question that some people often ask. By getting the Covid-19 vaccine, you are protecting yourself as well as reducing pressures on the NHS. Over 10 billion Covid-19 vaccines have been giving globally; and they have proven to be very safe and effective. The number of Covid-19 cases in the UK remains very high. Vaccines are protecting us and without them, we would be seeing many more people who are seriously ill or dying from Covid-19.

By getting vaccinated against Covid-19, you are substantially reducing your risk of a serious illness that may lead to you requiring hospital treatment or even dying. Even if you don’t need hospital treatment, Covid-19 can still be an unpleasant illness that can make you unwell for a few weeks or leave you with long-term complications.

The risks from Covid-19 are particularly high in those who are over 50 years of age, obese or who have underlying medical problems such as diabetes or kidney disease. Vaccination reduces all these risks to you. Furthermore, if too many people remain unvaccinated, this will increase the likelihood of the government having to introduce measures to control the spread of Covid-19 and reduce pressures on the NHS. This could mean, for example, bringing in restrictions on people attending large, indoor gatherings – or closing pubs, night clubs and restaurants – like the measures we have seen at times over the last two years.

It could even lead to another lockdown if pressures on the NHS were very high. These measures have had a big impact on people’s social lives and mental health, as well as on the economy, and we don’t want to see them brought back.

Finally, many countries across the world are now requiring proof of vaccination for tourists and visitors. If you are not vaccinated, you will find it difficult to visit these countries, thereby limiting your leisure opportunities or the chance to meet friends and family living overseas. So by getting vaccinated, you are not only helping the NHS. You are also helping yourself.

UK scales back routine Covid-19 surveillance

On 24 February 2022, the UK government removed the legal requirement for people in England to self-isolate after a positive covid-19 test result, with the other UK nations also easing restrictions.1 In doing so, the UK is acting ahead of many of its international peers to embark on a “vaccines only” strategy, hoping that existing immunity in the population will allow a “return to normal.” This view is in sharp contrast to public opinion. In a recent poll by market research company YouGov, only 17% of respondents thought that ending mandatory self-isolation was appropriate.2

The removal of legal restrictions makes the people of England part of an experiment in which much remains uncertain.3 This is acknowledged by chief government advisers Chris Whitty and Patrick Vallance, who accompanied Boris Johnson’s announcement with a warning that rates of covid-19 infection and hospital admission remain high.4 Of equal concern, the government’s announcement also introduced plans to scale back two crucial pillars of the UK’s covid-19 surveillance: the Office for National Statistics’ (ONS) covid-19 infection survey and daily reporting of data on the UK Health Security Agency (UKHSA) covid-19 dashboard.15 When, and to what extent, these important resources will be scaled back remains unclear.

The ONS survey is a world leading example of random population sampling to estimate covid-19 prevalence over time.67 The UKHSA dashboard has been a vital resource for the public, clinicians, journalists, and researchers, allowing them to identify local trends as well as providing national data. The dashboard received up to 19 million hits a week in September 2021.8 Data to understand and promptly respond to covid-19 outbreaks are essential for public health and the NHS, as well as for the wider public.

We remain in the middle of a global pandemic caused by a novel pathogen and complicated by the repeated emergence of new variants. Policy decisions to manage new outbreaks rely on robust and timely data—the alpha, delta, and omicron variants all became dominant in the UK within weeks of the first reported cases.9 Although omicron is associated with a significantly lower risk of hospital admission and death than previous variants, the government’s Scientific Advisory Group for Emergencies (SAGE) acknowledges that this may be the exception rather than the rule, emphasising the need for ongoing vigilance to detect future variants.10

From 1 April 2022, when universal free covid tests are withdrawn leaving only limited testing in place, most SARS-Co-V infections in England will remain undetected and unreported. Our ability to track the emergence of new variants or trends in the incidence of infection and disease will become more reliant on robust, cross sectional surveys such as the ONS survey. Scaling back the survey, as proposed, risks missing emerging variants or concerning rises in prevalence that could herald the need for further restrictions; moreover, the survey cannot provide accurate and timely local data, as currently provided by the UKHSA dashboard. The detrimental effects of delayed action are now abundantly clear, and we must not fall behind at this critical moment when the UK’s pandemic is gradually coming under control.11

In announcing the latest relaxation of restrictions, the prime minister asked the public to take individual responsibility for their actions, yet informed decisions are reliant on the availability and accessibility of information. Throughout the pandemic people have relied on regional reporting of covid-19 cases on government dashboards and in news media, and they will continue to need such accessible information for the foreseeable future.

While most people have received two or more doses of a covid-19 vaccine, almost 10% of adults in England have not received a single dose and around 30% have not had a booster.12 Many others remain at high risk of disease despite vaccination because of underlying health conditions. The public health implications of immunity waning over time remain uncertain.1314 As we move into a period of largely optional (and paid for) testing and voluntary self-isolation, it is crucial that people have easy access information to guide their actions and help minimise covid-19 risks to themselves and their families.

The UK has been a world leader in the routine surveillance of covid-19 and the transparent reporting of covid-19 data. Scaling back vital data systems prematurely is a false economy and may need to be reversed to manage future waves of infection. The UK has the resources and infrastructure to continue existing surveillance, which has clearly identifiable benefits. We need to sustain our existing surveillance capabilities until we are certain that the pandemic is over in the UK, which won’t be until covid-19 is controlled globally.

Jonathan Clarke, Thomas Beaney, Azeem Majeed

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

DOI: https://doi.org/10.1136/bmj.o562

Factors associated with accessing long-term social care in older people

The rise in demand for healthcare by an ageing population together with budgetary constraints has put great pressure on the availability of adult social care (ASC). In response, healthcare organisations and researchers have developed practices of care and support, focusing on prolonging functional independence  This is done through exploring possible risk factors associated with unplanned outcomes, typically readmissions to hospital or through the use of predictive models to forecast outcomes.

Predictive models are widely used by health care providers in the UK and US due to their potential to inform early interventions. However, equivalent models for predicting new onset of long-term ASC, defined as need for help with tasks of daily living in the community or in care homes, are rare, particularly those using administrative data.

In this study published in Age and Ageing, we describe risk factors for long-term ASC in two inner London boroughs and develop a risk prediction model for long-term ASC. Pseudonymised person-level data from an integrated care dataset were analysed. We used multivariable logistic regression to model associations of demographic factors, and baseline aspects of health status and health service use, with accessing long-term ASC over 12 months.

The cohort comprised 13,394 residents, aged ≥75 years with no prior history of ASC at baseline. Of these, 1.7% became ASC clients over 12 months. Residents were more likely to access ASC if they were older or living in areas with high socioeconomic deprivation. Those with pre-existing mental health or neurological conditions, or more intense prior health service use during the baseline period, were also more likely to access ASC. A prognostic model derived from risk factors had limited predictive power.

Our findings reinforce evidence on known risk factors for residents aged 75 or over, yet even with linked routinely collected health and social care data, it was not possible to make accurate predictions of long-term ASC use for individuals. We propose that a paradigm shift towards more relational, personalised approaches, is needed.

DOI: https://doi.org/10.1093/ageing/afac038

Should GPs in England be employed by the NHS?

The intense micromanagement of general practices by NHS England since the start of the Covid-19 pandemic in early 2020 has shattered the illusion that NHS general practitioners are truly “independent”. For example, during the pandemic, NHS general practices have often received weekly updates from NHS England on how they should provide primary care services.[1] The opening hours and working arrangements of general practices are also highly regulated by NHS England. And general practitioners are not independent contractors in the same way that professionals working in other fields or indeed primary care physicians working overseas would recognise. General practitioners are not even able to offer private medical services to their patients in the same way as NHS Trusts or dentists are able to do. In effect, they have all the disadvantages of being self-employed contractors and none of the benefits of being NHS employees.

For more than a decade, primary care in England has suffered from under-investment, and a lack of key staff such as general practitioners and practice nurses. The NHS hospital sector in contrast – although it also has its problems – has seen its funding and medical staffing increase at a much quicker rate than in NHS primary care.[2] And yet despite this, more NHS work continues to be shifted to primary care without being followed by a commensurate increase in funding and staffing. Attempts by NHS England to prevent this – such as the introduction of the NHS Hospital Contract – have failed.[3] It’s very clear that NHS England is not going to invest adequately in the current independent contractor model of general practice, making being a GP Partner increasingly unattractive for younger general practitioners.[4] It’s time therefore to look seriously at the alternative – GPs becoming salaried employees of the NHS.

Of course, being employed by the NHS is not a panacea. Many NHS staff employed by NHS Trusts suffer from stress and over-work, just like those working in primary care. But they are not personally responsible for the ownership of their employing organisations, and their income does not depend on how well their organisation performs financially. Their working hours are also better regulated than those of self-employed GPs.

If GPs had employment contracts similar to those of NHS consultants, they could then have job plans with time allocated for activities such as quality improvement, NHS management, teaching, training, and research. Currently, these activities are often done on top of their regular working hours. Working in organisations that employed large numbers of GPs would also create opportunities for a better career structure. For example, it may be possible to create posts for GPs who specialise in areas such as the care of the elderly or in child health; and for GPs who take on clinical leadership, quality improvement and NHS management roles in addition to a clinical role.[5]

Finally, GPs becoming NHS employees would make NHS England directly responsible for the delivery of primary care services, in the same way they already are for specialist services. It would be the responsibility of NHS England – not GPs – to ensure that patients had timely access to a comprehensive range of high-quality primary care services and the infrastructure needed to deliver this care.

An increasing proportion of NHS GPs are already salaried. The future for GPs therefore looks to be heading in this direction. The question for GPs is do they want to be employed by the NHS with similar terms of employment to consultants; or do they want to be employed by private companies and “mega-partnerships” with the inevitable variability in terms of employment that they will offer?

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

DOI: https://doi.org/10.1136/bmj.o406

References

1. Majeed A, Maile EJ, Bindman AB. The primary care response to COVID-19 in England’s National Health Service. Journal of the Royal Society of Medicine. 2020;113(6):208-210.

2. Anderson M, O’Neill C, Clark JM, Street A, Woods M, Johnston-Webber C, et al. Securing a sustainable and fit-for-purpose UK health and care workforce. The Lancet. 2021 May 22;397(10288):1992-2011.

3. Price A, Majeed A. Improving how secondary care and general practice in England work together: requirements in the NHS Standard Contract. Journal of the Royal Society of Medicine. 2018;111(2):42-46.

4. Rimmer A. GPs move towards industrial action after rejecting “rescue plan” for general practice BMJ 2021; 375:n2594

5. Majeed A, Buckman L. Should all GPs become NHS employees? BMJ 2016; 355:i5064

General Practice in England: The Current Crisis, Opportunities and Challenges

General practice or family medicine has historically been lauded as the “jewel in the crown” of the English National Health Service (NHS). General practice, at the heart of primary care, has continued to contribute to the high ranking of the NHS in international comparisons and evidence from several decades of research has shown that general practice in the UK has improved the nation’s health. Furthermore, it has provided equitable, cost-effective, and accessible care for all with the flexibility to adapt rapidly to a changing society and political climates, such as during the COVID-19 pandemic when there was rapid implementation of remote consultation models. However, this much-admired public sector service has recently come under unprecedented political and media spotlight instigated by the pressures of the current pandemic on the NHS. This coupled with collapsing morale among general practitioners (GPs), a shrinking GP workforce, inexorable demands, increasing workload, and decreasing real-terms per capita funding have caused many to sound alarm on a general practice in “crisis”. In this article published in the Journal of Ambulatory Care Management, we describe the evolving nature of general practice and the current crisis, as well as potential solutions and opportunities going forward.

The full article can be read in the Journal of Ambulatory Care Management.

DOI: 10.1097/JAC.0000000000000410

Covid-19: Implications of ending the legal requirement to self isolate for employers and people who are clinically vulnerable

The government has just announced that all covid-19 restrictions in England are set to end. Boris Johnson, the UK prime minister, told MPs that he plans to remove the remaining restrictions, including the legal requirement to self isolate for people infected with covid-19. Instead of legislation, voluntary guidance will “advise” people with covid-19 not to attend workplaces. Employers will once again need to develop and implement new rules for their workplaces when the legal requirement to self isolate with covid-19 comes to an end. They should consider carefully how to develop and implement new policies fairly and safely in the workplace so that staff and customers—particularly those who are clinically vulnerable—are not put at risk.

Presenteeism occurs when employees go to work despite not being well enough to perform their duties. The NHS is the largest employer in England and the NHS Staff Survey showed a drop in presenteeism in 2020 compared to preceding years. This is likely an effect of covid-19, which forced workers and employers to endorse sick leave to prevent workplace outbreaks and has therefore gone some way to changing attitudes to calling in sick. Despite this, around 40% of NHS staff surveyed still reported coming to work in 2020, despite not being well enough to work.

Reasons why employees attend work while unwell include financial pressures. Statutory sick pay (currently £96.35 per week in England) is the minimum amount employers must pay to unwell employees; though not all workers are entitled to statutory sick pay—loopholes include agency work and zero hour contracts in certain situations. Though some workers are entitled to contractual sick pay which is closer to their normal salary, for many workers in England, taking sick leave means taking home less money; and sometimes no money at all.

Now that the legal requirement to self isolate will be scrapped, the government has announced that they will return to pre covid provisions of sick pay, with self isolation payments ending. Statutory sick pay and employment support will no longer be paid immediately, but only after four and seven days of absence. Workers who voluntarily decide to self isolate, but are unable to work from home, will in some cases face a loss in pay. The end to financial support for people to self isolate, or take sick leave, is concerning as people will no longer be financially supported to stay at home if they are ill. Those workers who are unable to work from home are more likely to be older, from lower socio-economic groups, and from ethnic minority backgrounds—factors that have cumulatively contributed to a higher occupational risk of death from covid-19 over the last two years.

The need for local health and safety policies will also leave employers with a dilemma. Should employers develop internal policies mandating self isolation for those infected with covid-19 to protect their workforce and their customers? The Health and Safety at Work Act 1974 places responsibility upon employers to ensure “as far as reasonably practicable” that both employees and non-employees are protected from workplace risks. The Equality Act 2010 mandates that employers make “reasonable adjustments” for employees with disability to protect them from workplace discrimination. For example, a retail assistant undergoing chemotherapy for cancer, for whom working from home is not possible, may be at high risk of acquiring covid-19 at work with significant medical complications now that the legislation mandating self isolation is going to be withdrawn. Who takes on the responsibility for this risk, and how can discrimination along the social gradient or against those with disability be avoided?

Presenteeism is not good for the individual attending work while unwell, nor is it good for the organisation. Covid-19, even when asymptomatic, brings risks of workplace outbreaks with significant impact on the operation of services due to sickness absences. Employers should consider workforce wide policies to encourage self isolation with fair pay when employees are infectious with covid-19, now that the legal mandate will be removed. Where this is not possible, individual occupational health risk assessments for employees vulnerable to severe covid-19 infection and its consequences should inform reasonable adjustments to their workplace duties. This will include, for example, examining how many people are allowed into the workplace at one time, ensuring good indoor ventilation, and mitigation measures such as high quality face masks are used as appropriate.

Employers will also need to consider factors such as the vaccination status of their staff and current community covid-19 infection rates in their health and safety policies. Most adults in the UK have now had two covid-19 vaccinations, but a large proportion (around one in three) have not yet come forward for a booster vaccine. Recent data show that the booster dose is essential in reducing the risk of serious illness, hospital admission, and death from a covid-19 infection caused by the omicron SARS-CoV-2 variant. Employers will need to work with their staff to promote covid-19 vaccination, but as the recent reversal in government policy for mandatory vaccination of healthcare workers shows, this is not straight forward. For the time being, community covid-19 rates are falling from the very high levels we saw in late 2021; and may remain at tolerable levels during the spring and summer of 2022. By next winter, however, we can expect a seasonal increase in respiratory viral infections, which will coincide with waning population immunity, placing more people at risk from covid-19.

Losing progress away from presenteeism will be a backwards step in all sectors of the economy as well as putting the most vulnerable members of society at greater risk. By ending mandatory self isolation while also removing financial support packages, the government is failing to adequately support people in lower paid occupations to protect themselves and others from covid-19, and risks widening existing socio-economic and health inequalities

Lara Shemtob, Kaveh Asanati and Azeem Majeed

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

DOI: https://doi.org/10.1136/bmj.o461

Questions and Answers on the New Covid-19 Rules in England

If you only have mild symptoms how safe is it to go into an office or other workplace?

The question you should ask yourself is would you be comfortable being in the same office as someone who had a positive Covid-19 test the day before? Now that the legal requirement to isolate after a positive test in England is ending, employers will need to carry out risk assessments and implement their own infection control policies. My advice would be for employers to remain cautious for now and advise employees with symptoms or a positive Covid-19 test to stay off work for a period until we have more experience about the effect of the change in rules.

I’ve had plans to go for dinner and drinks with friends for a birthday party but have tested positive. If we’re all triple vaccinated how big a risk is it if I still go?

People who are fully vaccinated can still become infected. If you test positive for Covid-19, I would advise not attending the event, particularly if it is going to be in a crowded indoor venue where there is a significant risk of infecting others who are present. Although Covid-19 vaccination does substantially reduce the risk of serious illness and death, there is still a risk to older people and those who are clinically vulnerable even if they are fully vaccinated.

Will GPs and hospitals still only see you if you have no Covid symptoms?

If you have Covid-19 symptoms, you should inform your GP or hospital before they see you so they can take suitable precautions. We are still awaiting guidance for the NHS on how the new rules will operate for them, such as whether face masks will still be required in healthcare settings. However, because they deal with people who are clinically vulnerable, the NHS will need to take appropriate precautions to prevent someone with Covid-19 infecting other patients.

I was told to shield during the lockdowns, and now triple jabbed. Is it safe for me to go to places where people might have Covid?

If you are in a group that was advised to shield during lockdowns, Covid-19 still poses a risk to you even if you are fully vaccinated. You should continue to wear a well-fitting FFP2 mask in places like shops and on public transport. Whether you go to places with a higher risk of Covid-19 such as nightclubs is a personal decision that you need to take but I would advise being cautious until infection rates in the community fall further.

I work in a care home. What if I test positive, do I go into work as normal?

People living in care homes are at very high risk of a serious illness and death if they become infected for Covid-19. Care homes should therefore keep appropriate infection control measures in place, such as asking staff who test positive for Covid-19 to self-isolate for a period.

If everyone is going about normal life even if they have Covid, what’s likely to happen to infections and could it lead to herd immunity?

In recent weeks, the number of Covid-19 cases, hospital admissions and deaths have been falling. The high level of immunity in the population from vaccination and previous infection should keep the number of serious cases of Covid-19 at a manageable level. However, people’s immunity does decline over time, which is why the government has just announced that those at highest risk from Covid-19, people aged over 75 years and those with weak immune systems, will be offered another booster vaccination. The long-term future remains uncertain and we don’t yet know if an additional booster will be offered to a wider group of people later in the year. We also don’t know what will happen next winter when there may be a lower level of immunity in the population. Finally, there is always the risk that a more infectious variant of the coronavirus may emerge like the Omicron variant that we faced late in 2021. Unfortunately Covid-19 will remain with us for the foreseeable future and become part of our lives, like other respiratory infections such as flu.

These comments were first published in the Daily Mirror.

A national vaccination service for the NHS in England

The Health Secretary, Sajid Javid, announced on 26 January that a ‘national vaccination service’ is required to provide mass covid-19 vaccination to the population of England.[1] Speaking at a House of Commons Health and Social Care Committee meeting, Mr Javid suggested the proposed service could cover other vaccines as well as vaccines for covid-19. The rationale is that NHS General Practice is under great strain, and by removing some services that can be provided elsewhere, it will free up time for primary care teams to concentrate on their core work.

Traditionally, mass vaccine programmes in England have relied largely on general practices, increasingly supported by community pharmacies in recent years. This was demonstrated to great effect during the first wave of covid-19 vaccinations where the majority of vaccines were delivered by primary care teams. GP teams have secure electronic patient record systems, and are experienced in cold storage chains, and have medical support on site, including resuscitation equipment. Patients often know and trust their family doctors, and generally respond better to recalls for vaccination when these come from their own general practices. A move towards mass vaccine centres and away from primary care delivery may explain some of the recent slow-down in England’s covid-19 vaccine programme.[2]

The public need to be fully informed about what a national vaccination service will mean for them individually as well as the NHS. The majority of all NHS contacts occur in general practice, with around one million contacts per day.[3] This means that vaccines can be offered opportunistically when patients are attending for other reasons as well as in dedicated vaccine clinics. It also allows primary care teams to have discussions about vaccination during these consultations in patients who have concerns or questions about vaccines, or who are vaccine hesitant.

When attending for vaccination, patients also have the opportunity to discuss other issues in their health with their primary care team and to benefit from opportunistic health promotion. All this helps to ensure that vaccination is viewed holistically and not just as a transactional activity. This is particularly important for children where non-attendance for vaccination can sometimes be a safeguarding issue which requires a sensitive approach from primary care teams, as well as effective inter-agency working.

When the Prime Minister, Boris Johnson, announced that he wanted all adults England to be offered a covid-19 vaccine before the end of 2021 he looked to GPs to help. As a result, GPs were asked to drop all non-essential work and focus on vaccination for the remainder of the year. This caused much debate in the national and medical press about what the priorities should be for the NHS and for primary care. Suspending “non-essential work” will have adverse effects on people’s experience of the NHS and risks worsening health outcomes, particularly for poorer groups.[4] It is clearly also a policy that cannot be sustained for long or repeated frequently (for example, for another covid-19 vaccine booster programme later this year).

The current plan to consider a separate national vaccination service for covid-19 and possibly other vaccinations seems to be an effort to ensure that GPs are not asked to stop routine medical care again. Although investment in the NHS is welcome, and removing some workload from general practice might have merits, there are some caveats that must be considered before a new national vaccination service is established.

Firstly, any new vaccination service must be more cost-effective than existing models of delivery of vaccines, such as through general practices and pharmacists. At a time when NHS budgets are under great pressure, NHS funding must be used cost-effectively and services delivered efficiently. A new national vaccination service would require substantial funding to establish and run. For example, it is difficult to see how a national vaccine service could run effectively without full access to patients’ electronic medical records. It would also require premises from which to operate, and staff to manage and deliver the programme. We need the government to show how this investment in a new service would compare in terms of cost-effectiveness with a similar investment in primary care teams.

Secondly, a national vaccination service must achieve a high uptake of vaccination. We currently have very good uptake of most childhood vaccines in England and in 2021-22, primary care teams also achieved a record uptake of flu vaccines, for an extended group of patients compared to previous years. Vaccinations must also be delivered quickly and at scale when in a pandemic, and there must be a safe and robust system to target high risk groups; such as those with frailty, long term conditions, the housebound, people living in care homes, and patients from marginalised groups.[5]

Thirdly, creating a separate vaccination service risks further fragmentation of primary care. As we have already seen with the covid-19 NHS 119 service, many patients will still contact their GPs about vaccination queries, even if this is no longer part of the NHS GP contract. This risks creating extra work for primary care teams that is not part of their core contract and for which they will not be paid; and will also be very frustrating for patients who will have to deal with more than one healthcare provider to have any issues they have about their vaccinations and how these vaccinations are recorded are dealt with. Finally, a newly established national vaccine service may recruit staff from primary care teams, both clinical and non-clinical, thereby further worsening the current shortages of staff in NHS primary care.[6]

The government must therefore carefully examine the merits of a separate national vaccination service; and any problems it may cause for existing services; including how it might affect vaccine uptake. Investing in and strengthening existing NHS primary care infrastructure in general practices and pharmacies may be a more cost effective option. Because of the importance of vaccination in allowing England to move to “living with covid-19”, vaccinations programmes must be implemented well and achieve a high take-up, particularly in the groups most at risk of serious illness, complications and death from infectious diseases such as covid-19. We cannot risk undermining the current vaccination systems that already work efficiently and cost-effectively in England’s NHS. Any proposals for a new national vaccination service must therefore be assessed with the same rigour we would with any new medical treatment with serious consideration of the risks as well as the benefits.

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

DOI: https://doi.org/10.1136/bmj.o338

References

  1. Health secretary proposes ‘national vaccination service’ to relieve GPs.https://www.pulsetoday.co.uk/news/breaking-news/health-secretary-proposes-national-vaccination-service-to-offload-gps/
  2. Where are we with covid-19 vaccination in the United Kingdom?https://blogs.bmj.com/bmj/2021/07/09/where-are-we-with-covid-19-vaccination-in-the-united-kingdom/
  3. Appointments in General Practice.https://digital.nhs.uk/data-and-information/publications/statistical/appointments-in-general-practice–weekly-mi/current
  4. Majeed A, Maile EJ, Bindman AB. The primary care response to COVID-19 in England’s National Health Service. Journal of the Royal Society of Medicine. 2020;113(6):208-210.
  5. Covid-19 vaccines: patients left confused over rollout of third primary doses.https://blogs.bmj.com/bmj/2021/10/15/covid-19-vaccines-patients-left-confused-over-rollout-of-third-primary-doses/
  6. Oliver D. Act on workforce gaps, or the NHS will never recover BMJ 2022; 376:n3139

Reducing the covid-19 isolation period in England: a policy change that needs careful evaluation

How long people with covid-19 should self-isolate depends on the period for which they remain infectious. On 4 January, the US Centers for Disease Control (CDC) updated covid-19 isolation and quarantine recommendations with shorter isolation (for asymptomatic and mildly ill people) and quarantine periods of 5 days to focus on the period when a person is most infectious, followed by continued masking for an additional 5 days.1 This policy was based on a modelling study from the United Kingdom by Bays et al which showed that after the 5th day after a positive test, an estimated 31% of persons remained infectious.2 All the authors of this modelling study, which was published as a pre-print on 24/12/2021, work for UK Health Security Agency (UK HSA).

On 22 December 2021, the UK HSA reduced self-isolation for covid-19 cases in England from 10 to 7 days following negative lateral flow tests on days 6-7. The UK HSA stated that that a 7-day isolation period alongside 2 negative lateral flow tests had nearly the same protective effect as a 10-day isolation period without testing for people with covid-19.

On 1 January, the UK HSA published a blog on using lateral flow tests to reduce the self-isolation period.3 The blog provides background to explain the reasons for the difference between the policies. It also stated that after 10 days self-isolation, 5% of people will still be infectious; and that ending self-isolation after 7 days and two negative lateral flow tests resulted in a similar level of protection.

The two negative test results are essential in safely supporting the end of self-isolation. Without testing, modelling suggests that 16% of people would still be infectious after day 7.  On 13 January, the Health Secretary Sajid Javid stated that from 17 January people will be able leave isolation from the start of day six after two negative lateral flow tests on days 5-6.

Both the US CDC and the UK HSA have based their length of isolation policy mainly on a single modelling study. The data on which the modelling was based It is therefore very important. Bays et al provide a single reference for “infectious period distribution”, a UKHSA modelling paper by Birrell et al published on 31 May 2021.4 Hence, it did not contain any information about the Omicron variant of SARS-CoV-2. It gives as a data source: “the Wuhan outbreak additionally provides information on epidemiological parameters: the duration of infectiousness, the mean time from infection to symptom onset; the probability of dying given infection and the mean time from symptoms onset to death”.

The Wuhan report by Li et al was published in New England Journal of Medicine on 26 March 2020.5 It does not contain any empirical information on the time for which cases were infectious. It only estimates the mean serial interval (MSI), based on six cases only, which represents the average time between the time of symptom onset of a primary case and that of a secondary case.6 The MSI is widely used in infectious disease surveillance and control because it allows investigators to identify epidemiologic links between cases and to diagnose new cases that have such epidemiologic links with laboratory-confirmed cases.  The MSI in Li et al is 7.5±3.4 days (95% CI, 5.3 to 19). There is no information specifically about infectious periods.

Policies in both the UK and US are based on limited data and only on the wild-type SARS-CoV2 variant. Ideally, there should be population-based studies which included daily monitoring of culturable Omicron variant viral shedding (or even better actual transmission, which should be available from large databases) and PCR and lateral flow testing. A 2020 (so pre-Delta) rapid scoping review and analysis from Ireland of available evidence for serial testing asymptomatic and symptomatic cases showed substantial variation in the estimates, and how the infectious period was inferred.7 One study provided an approximate median infectious period for asymptomatic cases of 6.5–9.5 days. Median pre-symptomatic infectious period across studies varied over <1–4 days (and there are several recent studies of the Omicron incubation period showing it is short). Estimated mean time from symptom onset to two negative RT-PCR tests was 13.4 days (95% CI 10.9 to 15.8), but was shorter when studies included children or less severe cases. The only currently available study of the Omicron variant is a small Japanese report which showed the number and percentage of Omicron variant virus isolation positive samples as 7/17 (41.2%) after three to six days and 2/18 (11.1%) at seven to nine days.10

The change in isolation policy for people with covid-19 in England is a pragmatic step that will allow people to return to productive work, education and social activities more quickly. People may also be more likely to comply with a shorter isolation period. But the changes should have been based on careful monitoring and review based on new data on the Omicron variant, not on data on the wild type of SARS-CoV-2. We therefore need careful evaluation of the new shorter isolation period to ensure that people are following the guidance on self-testing and symptoms, and not ending their isolation period too early, and thereby putting others at risk of infection from covid-19.

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

DOI: https://doi.org/10.1136/bmj.o184

References

  1. US Centers for Disease Control. What We Know About Quarantine and Isolation: Why CDC Shortened Isolation and Quarantine for the General Population: US Centers for Disease Control, 2022.
  2. Bays D, Whiteley T, Pindar M, et al. Mitigating isolation: The use of rapid antigen testing to reduce the impact of self-isolation periods.medRxiv2021:2021.12.23.21268326. doi: 10.1101/2021.12.23.21268326
  3. UK Health Security Agency. Using lateral flow tests to reduce the self-isolation period: UK Health Security Agency, 2022.
  4. Birrell P, Blake J, van Leeuwen E, et al. Real-time nowcasting and forecasting of COVID-19 dynamics in England: the first wave.Philosophical Transactions of the Royal Society B: Biological Sciences2021;376(1829):20200279. doi: doi:10.1098/rstb.2020.0279
  5. Li Q, Guan X, Wu P, et al. Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus–Infected Pneumonia.New England Journal of Medicine2020;382(13):1199-207. doi: 10.1056/NEJMoa2001316
  6. Vink MA, Bootsma MCJ, Wallinga J. Serial Intervals of Respiratory Infectious Diseases: A Systematic Review and Analysis.American Journal of Epidemiology2014;180(9):865-75. doi: 10.1093/aje/kwu209
  7. Byrne AW, McEvoy D, Collins AB, et al. Inferred duration of infectious period of SARS-CoV-2: rapid scoping review and analysis of available evidence for asymptomatic and symptomatic COVID-19 cases.BMJ Open2020;10(8):e039856. doi: 10.1136/bmjopen-2020-039856
  8. van Kampen JJA, van de Vijver DAMC, Fraaij PLA, et al. Duration and key determinants of infectious virus shedding in hospitalized patients with coronavirus disease-2019 (COVID-19).Nature Communications2021;12(1):267. doi: 10.1038/s41467-020-20568-4
  9. Monel B, Planas D, Grzelak L, et al. Release of infectious virus and cytokines in nasopharyngeal swabs from individuals infected with non-B.1.1.7 or B.1.1.7 SARS-CoV-2 variants.medRxiv2021:2021.05.20.21257393. doi: 10.1101/2021.05.20.21257393
  10. National Institute of Infectious Diseases Disease Control and Prevention Center. Active epidemiological investigation on SARS-CoV-2 infection caused by Omicron variant (Pango lineage B.1.1.529) in Japan: preliminary report on infectious period: National Institute of Infectious Diseases Disease Control and Prevention Center, National Center for Global Health and Medicine, 2022. https://www.niid.go.jp/niid/en/2019-ncov-e/10884-covid19-66-en.html

Why the government’s new policy on face masks in England is a retrograde step

The government announced today that face masks will soon no longer be mandatory in England. Why is this a retrograde step in controlling the spread of Covid-19?

Covid-19 is an infection that is largely spread indoors – particularly in crowded, poorly ventilated areas – through inhaling droplets and aerosols produced by infected people when they cough, sneeze, sing, talk, or breathe. Face masks are a simple method of reducing the risk of infection – but masks work much better if they are worn by large numbers of people. The main function of a mask is to reduce the emission of droplets from infected people into the air. The droplets are captured by the mask and hence less virus enters the air. Much of the benefit of wearing face masks goes to other people but they can also benefit the wearer, particularly if a high-specification FFP2 mask is worn that filters out more particles and droplets when the wearer breathes in air.

Wearing face masks will reduce the spread of the coronavirus and help protect others. This is very important in settings where we are in contact with older and more vulnerable people – such as in supermarkets and on public transport. Wearing a mask has no major side effects, and does not change a person’s oxygen or carbon dioxide levels. Widespread wearing of face masks has been an important part of the pandemic control strategies of countries that have been more successful in containing the spread of Covid-19.

Vaccines are essential and can protect us from developing a more serious illness, as well as reducing the risk of death. But we must maintain the use of other control measures, such as the use of face masks, until we are past the worst of the Covid-19 pandemic.