Tag: Covid-19

What can we do to reduce the risk of another lockdown this Winter?

We all want to avoid another lockdown. We need sustainable public health interventions that will keep Covid-19 cases, hospitalisations and deaths at an acceptable level, and get us through the winter. What could this mean in practice?

1. The most important public health intervention to control Covid-19 is our vaccination programme. This has slowed down in recent months. Also, in effect, it has split into four distinct programmes:

– a programme aimed at people 16 and over. This has almost stopped, with around 10% of adults in the UK still unvaccinated (higher in London).

– a third primary dose programme aimed at people with weak immune systems. This has been poorly planned and implemented by NHS England and has caused a lot of confusion.

– a booster dose programme. This is going OK but could be speeded up to provide more protection for key groups of people before the full onset of winter.

– a programme for 12-15 year olds. This has got off to a very slow start in England.

Speeding up all these vaccination programmes is essential and is our best defence against Covid-19.

 

2. Try to reduce social contacts; for example, by asking staff to work from home where possible. The government has been encouraging people to “get back into the office” but I think we should be cautious over the winter.

 

3. Face masks. The government needs to reconsider its policy. In my view, face masks should be required in settings such as shops and public transport.

 

4. Vaccine mandates / vaccine passports / negative test results. Many European countries require these for entry to higher risk settings such as nightclubs, bars and indoor events. No vaccine is 100% effective but the fact is that an unvaccinated person is much more likely to become infected and transmit infection to others than a vaccinated person. The government has flipped-flopped on this policy (currently against) but have said they may reconsider.

 

Effective measures now can help bring Covid-19 under control, protect public health, keep pressures on the NHS manageable, and get us through the Winter.

Extending the duration of Covid-19 control measures in England

There will be a lot of disappointment about the 4-week delay to the relaxation of Covid-19 control measures in England until 19 July that was announced today by the Prime Minister. But it is the right decision. A delay of a few weeks allows more people to be fully vaccinated with two doses of a Covid-19 vaccine. The vaccination programme in the UK is progressing well; with 79% of adults in the UK having received one dose of a vaccine and with 57% who have received two doses. But this still leaves many adults unvaccinated, including some people in the 50+ age groups who are at highest risk of serious illness, hospitalisation and death.

The delta variant in circulation in the UK appears to be more infectious and more likely to result in an illness severe enough to require hospitalisation than other strains of SARS-CoV-2; and now accounts for the vast majority of Covid-19 infections. One dose of a Covid-19 vaccine is less effective in preventing symptomatic infection from the delta strain than other variants (e.g. 33% protection after one dose for the delta variant v. 88% for alpha variant based on data from Public Health England). Two doses still provides good protection (81% protection against the delta variant v. 88% protection against the alpha variant for symptomatic infection, with even greater protection against hospitalisation), which is why it is essential to increase the number of fully immunised people before relaxing control measures. Delaying the relaxation of lockdown measures allows time for the NHS to proceed further with its vaccination programme.

We have seen around a 50% increase the in the number of cases of Covid-19 in the UK in the past week. The positive news is that hospital admissions, although increasing, are at a low level; and that deaths have changed little, remaining at a very low level compared to January 2021. This suggests that vaccines are protecting against more serious illness and confirms the need for eligible people at obtain their Covid-19 vaccination as soon as possible.

In the longer term, a high level of vaccination in the UK population offers the best route to a more normal society and an end to Covid-19 restrictions. This requires giving the NHS – in particular, general practices and pharmacies – the support they need to deliver vaccinations. If possible, the government also needs to increase the supply of vaccines; particularly the Pfizer and Moderna vaccines as these are the ones used in younger people who now comprise the majority of the unvaccinated adults in the UK. It’s also essential to address “vaccine hesitancy” to ensure that vulnerable, older people who have not yet attended for their vaccination appointments do get vaccinated to protect themselves and others. These actions will allow the NHS to meet the government’s updated target of offering all adults a Covid-19 vaccine by 15 July, as well as increasing the number of people who have received two doses of vaccine.

Measuring the impact of Covid-19: Why mortality alone is not enough

In an editorial published in the British Medical Journal, we discuss why we must look beyond mortality to the wider burden of pandemic related harms. Over the course of the covid-19 pandemic, daily releases of national statistics on cases and deaths have been widely reported and used to support interventions and judge the success or failure of control measures around the world. However, differences in rates of testing and in reporting of deaths have led to uncertainty about whether national headline figures on deaths are directly comparable. Excess mortality is an alternative metric, which gives a measure of the number of deaths above that expected during a given time period and thus accounts for additional deaths from any cause during the pandemic, irrespective of how covid-19 deaths are defined.

Measuring excess mortality alone offers only partial insights into the impact of the covid-19 pandemic on the health of nations. If we are to truly understand and intervene to mitigate the impact of the pandemic, we must also look to quantify excess morbidity within and between nations. A focus on deaths alone gives only a partial picture of the impact of covid-19 on populations, particularly among younger people in whom death from covid-19 is rare. The importance of “long covid,” for example, has recently been highlighted, but the true burden of this condition has yet to be quantified, and policies are urgently needed to overcome its long term challenges.

The covid-19 pandemic has resulted in widespread disruption to health systems across the world. Diagnostic and treatment pathways for cancer and other time sensitive conditions have been disrupted, and the monitoring of long term conditions has often taken place through novel telemedicine platforms, if at all. By April 2021 more than 4.7 million people in England were waiting for hospital treatment, the highest number since records began. Such disruption is likely to lead to poorer health and earlier deaths in countries across the world for many years to come, particularly where covid-19 remains endemic and where health services are unable to function normally. Establishing where health systems have fallen behind, and characterising the true extent of unmet need, is a critical step towards reducing these ongoing harms.

There has been a huge toll of the covid-19 pandemic on mortality in high income countries in 2020. However, its full impact may not be apparent for many years, particularly in lower income countries where factors such as poverty, lack of vaccines, weak health systems, and high population density place people at increased risk from covid-19 and related harm. In the UK, life expectancy in lower socioeconomic groups has fallen in recent years, an inequality likely to be exacerbated by the covid-19 pandemic, without concerted action.

Finally, although mortality is a useful metric, policy informed by deaths alone overlooks what may become a huge burden of long term morbidity resulting from covid-19. An urgent need exists to measure this excess morbidity, support people with long term complications of covid-19, and fund health systems globally to tackle the backlog of work resulting from the pandemic.

DOI: https://doi.org/10.1136/bmj.n1239

How is the Covid-19 lockdown impacting the mental health of parents of school-age children?

The Covid-19 pandemic has affected educational systems worldwide, leading to the near-total closures of educational institutions in the UK. As of 6 May 2020, schools were suspended in 177 countries affecting over 1.3 billion learners worldwide, and in many cases closures have resulted in the universal cancellation of examinations. UNICEF estimated that almost 4 months of education will be lost as a result of the first lockdown.

School closures have far-reaching economic and societal consequences, including the disruption of everyday behaviours and routines. In the UK, over 2 million workers have already lost their jobs, and although the long-term impact of the pandemic on education is not yet clear, the pre-existing attainment gap between the poorest and richest children7 may widen significantly as a result of COVID-19. Children and young people make up 21% of the population of England,10 and by the time they returned to school after the summer break, some would have been out of education for nearly 6 months.

In a paper published in the journal BMJ Open, we explored how the lockdown affected the mental health of parents of school-age children, and in particular to assess the impact of an extended period of school closures on feelings of social isolation and loneliness.

We collected data for 6 weeks during the first 100 days of lockdown in the UK and found that female gender, lower levels of physical activity, parenting a child with special needs, lower levels of education, unemployment, reduced access to technology, not having a dedicated space where the child can study and the disruption of the child’s sleep patterns during the lockdown are the main factors associated with a significantly higher odds of parents reporting feelings of loneliness.

We concluded that school closures and social distancing measures implemented during the first 100 days of the COVID-19 lockdown significantly impacted the daily routines of many people and influenced various aspects of government policy. Policy prescriptions and public health messaging should encourage the sustained adoption of good health-seeking self-care behaviours including increased levels of physical activity and the maintenance of good sleep hygiene practices to help prevent or reduce the risk of social isolation and loneliness, and this applies in particular where there is a single parent. Policymakers need to balance the impact of school closures on children and their families, and any future risk mitigation strategies should ideally not be a further disadvantage to the most vulnerable groups in society.

DOI: http://dx.doi.org/10.1136/bmjopen-2020-043397

Staying safe at the beach and the park

With the weather improving and people in England now allowed to meet with others outdoors, we will be heading to the beaches and parks. Being outdoors and getting exercise are essential for our physical and mental health but also comes with some risks because of the Covid-19 pandemic. Here are some steps you can take to protect yourself and others from the risk of infection.

Travelling safely. If you are travelling by car, try to travel with people from your household or support bubble. If using public transport, make sure you wear a face mask. The best way to travel is by foot or bicycle but this won’t be practical for more distant locations.

Follow Covid-19 rules on how many people can meet. In England, you can currently meet with a maximum of five other people if they are from more than two other households. Make sure your total group size does not exceed six people if this is the case. If there are people from just two households meeting, then your group can be bigger than six people.

Keep your distance from other people. There will be many other people also out and about. Try to keep at least two metres away from others who are not in your group if they will be near you for a prolonged period. The virus that causes Covid-19 spreads from person to person by droplets or through an aerosol. Outdoors, the virus will disperse quickly and the risk of infection is very low if you are not near other people.

Don’t share food and drink. You should use separate cups, plates and utensils for each person present and not share them as sharing will increase the risk of infection. You should also avoid sharing food because this has been shown to increase the risk of infection.

Be aware of the greater risks in indoor spaces such as toilets. At some point, you may have to use to use a public toilet. The risk of infection is substantially higher in indoor spaces – particularly if they are crowded, used by lots of people and are poorly ventilated. Avoid coming into close contact with others while indoors. You should also wear a face mask or face covering, and wash or sanitise your hands before entering. After using the toilet, wash your hands thoroughly and go back outside immediately once you finish.

Avoid touching surfaces. Surfaces such as hand rails will have been touched by many other people and will be contaminated. If you do touch a surface that many people have been in contact with, wash or sanitize your hands as soon as possible.

Wash your hands or use hand sanitizer regularly. This will remove any virus that you may have inadvertently picked up from a surface or from someone else, and help to protect yourself and protect others.

Don’t drink too much alcohol. People are far more likely to engage in behaviour that increases their risk of infection if they have been drinking heavily. Ensure you maintain your self-control and remain aware of the people around you.

Don’t go out if you are unwell or are self-isolating. Don’t go out if you feel unwell, have symptoms of a possible Covid-19 infection, or if you are self-isolating because you have been in contact with someone else with Covid-19. If you break these rules, you are putting others at risk.

Avoid mixing indoors afterwards. It may be very tempting for your group to go back to a friend’s house for a drink or get together after your day out but this is a breach of the current Covid-19 regulations on people from different households mixing. The risk of infection is far higher indoors than outdoors, which is why the government prohibits indoor mixing.

Most importantly, get vaccinated. The UK’s Covid-19 vaccination programme is now well underway. If you are eligible for a vaccination, please book your appointment. If you have not yet been invited, please do attend for your vaccination when you are invited. Vaccination protects you and protects others, creating a safer environment for everyone and provides a route to a return to a more normal way of living.

Questions and answers about England’s new Covid-19 rules

Can I have a BBQ on the front of my house with others from my street?

Under the Rule of Six, you can only meet with a group of more than six if they are from your household and one other household (a maximum of two households). For example, if there were four people in your household and four in another household, the eight of you could meet for a BBQ as you are from two households. If your group is from more than two households, then a maximum of six people can meet, so you could not hold a BBQ for your entire street.

 

Can I use my friend’s toilet?

You are allowed to use your friend’s toilet if this is necessary. You should though avoid interacting or coming into close contact with anyone from your friend’s house while you are indoors as this is where the risk of infection is greatest. You should also wear a face mask or face covering whilst indoors, wash or sanitise your hands when entering the house, and spend the minimum time indoors. After using the toilet, wash your hands thoroughly, ideally using a separate towel or disposable hand towels, and go back outside immediately once you finish.

 

Can I meet with five mums and their kids in a park?

Large parent and child groups can only take place outdoors if they are for the benefit of children aged under five and organised by a business, charity or public body. If this was an informal meeting, however, you would need to limit the group to a maximum of six people. So, if you had five mums, only one child could join because children count towards the size of the group

 

If I can meet up with a BBQ, what are the rules around cups, plates, utensils?

There are no specific rules around cups, plates, and utensils but you should practise good infection control measures at a BBQ. You should use separate cups, plates and utensils for each person present and not share them as sharing will increase the risk of infection. You should also avoid sharing food because this 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 Covid-19 but also for gastroenteritis).

 

Can I now chat with other mums in the school playground?

The same rules apply while you are in the playground as in other outdoor settings so you could only chat to a maximum of five other mums. However, schools would not look favourably on large groups of parents mixing in their playgrounds as they know this would increase infection risks and so may discourage such groups meeting on their grounds.

 

Now I’m allowed to see my mum who lives in another county, can I stay overnight in a hotel so I can spend more time with her?

This is a grey area as overnight stays away from home are only allowed for specific purposes. If this was a social visit, an overnight stay away from home would generally not be allowed. However, the rules also state that you can stay away from home overnight if you are unable to return to your main residence the same day. So, if your mother lived too far away for you to visit and return the same day, an overnight stay may be permissible

 

Can two households and the people in both their support bubbles meet, even if there will be 15 people?

You can meet in a group of any size from up to two households, including members of any existing support bubble. So, a group of 15 can meet outdoors if they are from a maximum of two households and their respective support bubbles.

 

Now I’m allowed to go walking outside my local area, am I allowed to camp overnight?

You can go walking outside your local area but an overnight camp would not be allowed as this would be seen as being for a non-essential purpose.

 

Can 10 people meet up for a game of five-a-side football?

10 people could only meet for an informal game of five-a-side football outdoors if they are from a maximum of two households. If they are from more than two households, they would exceed the maximum number of six people who can get together. You can take part in formally organised outdoor sports with any number of people but this must be organised by a business, charity or public body, and the organiser must take the required infection control precautions,

 

Are we on track to open shops, theme parks and gyms on April 12? What might set it back?

We are on track to open a wider range of businesses on April 12 because Covid-19 case numbers, hospital admissions and deaths are all currently falling in England. If there was a rapid increase in the number of cases in the next 1-2 weeks, this might lead the government stop this re-opening of businesses but this looks unlikely to be the case.

 

Could a hairdresser come and cut my hair in my garden?

As your haircut is taking place outdoors and only two people are involved, this is permissible under the rules. Your haircut though can’t take place indoors or at the hairdresser’s premises for now.

 

Can I conduct my yoga class in my garden or a park?

If this is a formally organised event held by a qualified yoga instructor or by a yoga club, then you can conduct your class outdoors without limits on numbers. You can’t however meet for an informal yoga session with your friends if this breached the rules on the maximum number of people who can get together.

 

Will more people than just the designated person be able to visit my mum in the garden of her care home?

Care homes can offer visits to other friends or family members if these take place outdoors, such as in the garden of the care home. You need to be mindful though that care home residents have a very high risk of serious illness and death if they contract Covid-19, so good infection control measures must be followed. Ideally, the visitors should also have been vaccinated as should your mum.

 

Can I go to the beach?

Yes, you can visit a beach but overnight stays away from home would not be allowed for this purpose, so you would need to be able to go to the beach and return home the same day.

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

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

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

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

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

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

The primary care response to COVID-19 in England’s National Health Service

In a recent article, I discuss the primary care response to Covid-19 in England. The first case of COVID-19 in England was identified at the end of January 2020. Cases increased during February, and by early March, it became apparent that England faced a large COVID-19 epidemic. This led to the Department of Health and Social Care and NHS England (the bodies that respectively fund and manage the NHS in England) to recommend radical changes to the provision of NHS primary care services.
For most general practices, these changes began to be implemented in the week beginning 16 March 2020. As a first step, general practices switched from the traditional model of face-to-face service provision to one where all patients were initially assessed through a telephone or a video call. Patients were encouraged to register for online booking of these appointments if they had not already done this.
All patients requesting advice spoke first to a health professional, usually general practitioners. The aim was to deal with as many queries as possible by telephone or a video call. Patients who required a face-to-face appointment were booked to be seen in later that day. This ensured that patients were largely managed on the same day they sought medical advice. These changes have resulted in around three-quarters of patients being managed remotely compared to the same time last year when only one-quarter were, with the total volume of primary care activity falling by about 25%.
We have seen rapid changes in primary care in England, but challenges remain, particularly if the number of people with COVID-19 infection increases rapidly and starts to overwhelm the health system, or if second and subsequent waves of infection occur. Other challenges include providing medical care for people who are self-isolating at home because of their age or because of underlying medical problems that increase their risk of complications and death if they contract a COVID-19 infection. There are also problems that will arise from the cutting back of many specialist hospital services, which will have negative effects on health outcomes if restrictions in health services remain in place for a prolonged period.
Overall, primary care in England has responded well to the COVID-19 pandemic, making radical changes to how primary care services are delivered in a very short period of time. Key to allowing this to happen is the commitment by the UK government to support general practices financially to prevent the loss of income that has occurred to primary care practices in countries such as the USA. However, the future will remain challenging for primary care teams in England until such time as a vaccine or effective drug treatment can be found for COVID-19.
Read the full article in the Journal of the Royal Society of Medicine.

Health inequalities: the hidden cost of COVID-19

My article in the Journal of the Royal Society of Medicine discusses the wider impact of COVID-19 on health systems and the potential for changes to health services to increase health inequalities. We report a 44% decrease in emergency department attendances in England in March 2020. We must not overlook the importance of good infection control for outsourced NHS staff such as cleaners, security guards and caterers. They can acquire COVID-19, thereby putting themselves at risk, and transmit COVID-19 to patients and other NHS staff.
Read the full article in the Journal of the Royal Society Medicine.

Protecting healthcare workers during the COVID-19 pandemic

My editorial in the British Journal of General Practice discusses how we can protect healthcare workers during the Covid-19 pandemic. Some of the key steps we can take include:
1. Maximise remote working
2. Implement good infection control
3. Use PPE effectively.
4. Risk assessment for staff based on age and medical history
Too many health and care workers have died and we must take urgent action to protect them. When we protect staff, we also protect patients because we reduce the risk of hospital acquired infection.
Read the full article in the British Journal of General Practice.