What is COVID-19?

• COVID-19 is a new RNA virus from the coronavirus family that includes SARS (Severe Acute Respiratory Syndrome) and MERS (Middle East Respiratory Syndrome). It is thought to have started in an live animal market in China.
• The main method of transmission is respiratory droplets, or, in a healthcare setting, contact with bodily fluids.
• Treatment is supportive. That is helping the patient with breathing, giving fluids and medication to bring temperature down. It is not known if antivirals are effective. There is currently no vaccine.

The British Medical Journal suggests (BMJ 202;368:m800):

•  Average time from contracting the illness to showing signs of the disease (incubation period) of 5–6 days but it can range from 1 to 14 days
• >80% have mild disease, 15% get severe disease including pneumonia, 5% become critically unwell.
• 2% overall of people who get the disease will die from it (0.2% in those <50y, 15% in those >80y). Those with long term chronic diseases are also at higher risk. These are usually people who we will give the flu jab to every year. If you are over 80 years old and with a long term disease you will be at the highest risk.

When should you consider COVID-19?

IMPORTANT: THIS CHANGED SIGNIFICANTLY ON MONDAY 16 MARCH:

• The virus is assumed to be moving freely in the community so travel history or contact with an infected person are not required to suspect COVID-19.

• Only those being admitted will be tested. There is clear guidance on how to manage these patients (summarised below).

• Those with ‘possible COVID-19’ (defined below) who are well enough to stay at home are asked to self-isolate ALONG WITH THEIR WHOLE HOUSEHOLD and follow ‘stay at home’ guidance for a period of time

Definition of ‘possible case of CoVid-19’ in those well enough to remain in the community:

• New continuous cough.

• High temperature (not defined in primary care criteria, ≥37.8 in hospital definition).

It is worth nothing that patients with low immunity such as patient on chemotherapy may not develop a fever. As a results were have an extensive telephone triage system in place to decide if and when to see such patients.

• If your do fall in this group and you are unwell, we will telephone you and we may see you apart from other patients.
• We will try and see you at the end of the morning if your symptoms will allow it.
• A designated clinician , wearing personal protection equipment rather than your usual clinician will see you.
• You will also be asked to wear a mask.

Definition of ‘possible case of CoVID-19’ in those requiring admission to hospital:

Anyone with  ANY of the following:

1.    Acute respiratory distress syndrome (ARDS) – symptoms and sings are; laboured or rapid shallow breathing, at least over 24 breaths a minute, generalised muscle weakness, tiredness,  feeling faint or dizzy when standing up, blue discolouration of lips and nails, cough, fever, headaches, rapid pulse usually over 100 beats a minute, drowsiness and confusion.

OR

2.    Clinical signs of pneumonia – determined by chest examination only but the symptoms are as those for ARDS along with temperature.

OR

3.    Influenza-like illness is defined as T≥37.8C AND at least 1 of (acute onset) sore throat, hoarseness, sneezing, nasal congestion/discharge, cough, wheeze, shortness of breath.

If you have any these symptoms and signs in 1 to 3 you or your relatives can call 111 and tell the operator hat you suspect you have acute respiratory distress syndrome or clinical pneumonia. If you are a relative and the patient cannot speak or appears confused then you can call 999.

NEW! ‘Stay at home’ guidance for those with ‘possible COVID-19’

A test will not be offered for those with ‘possible COVID-19’ who do not need admission, but they will be advised that the whole household should follow ‘stay at home’ guidance

What does ‘stay at home’ mean?

To protect others in the community

• Not leaving the house and, if living with others, minimising sharing space with others.

In an ideal world, this means:

• Sleeping alone.
• Not sharing a bed, toothbrush, crockery, towels or food.
• Staying in one room, into which others do not go, as much as possible. If rooms do need to be shared, using them when others are not present.
• If possible, using a separate bathroom; if this is not possible, the patient cleans the bathroom after each use.
• If possible, having meals brought to the room rather than the patient preparing them in a shared space.
• Regular hand washing by all in the household, with the patient having a separate towel from the rest of the house-hold.

Looking after yourself

• Identify those who can help provide supplies (dropping on the doorstep, not stopping to chat!), and keeping in touch by phone/social media, not face to face.
• Can you exercise? If essential, yes, but keep a safe distance (at least 2m) from others.
• Can you go in the garden? Yes.
• Breastfeeding is safe (there is no evidence that COVID-19 is transmitted through breast milk).
• Pets are not at risk of getting coronavirus.

Detailed patient guidance is available here:

www.gov.uk

NEW! Returning to normal activity

This is complicated and work in progress for now this is the advice;

 The rationale, I think, is this:

• Isolation of symptomatic people reduces spread.
• Isolating asymptomatic people who live with a symptomatic person stops the asymptomatic person spreading it while incubating it, before they develop symptoms. This reduces spread to the community.

So, the principles are:

• Those that develop symptoms must self-isolate for SEVEN days. After 7 days, if they are well, they can return to normal activities. After coronavirus, people are likely to continue to cough for some weeks: they can return to normal even if they are still coughing. This cough is the usual post-viral cough that some patients have after a viral infection.
• EVERYONE in the household of the index case needs to isolate for FOURTEEN days (to stop spread to the community). (Index case = first person to get sick in the household.)
  • If, during the 14 days, a household member develops symptoms, they can return to normal activities SEVEN days after the first day of their symptoms (provided they are well), even if they are still within the 14 days (they are no longer a risk to the community as they have had it and got better).
  • Any member of the household who does NOT develop symptoms can return to normal activities after FOURTEEN days isolation FROM THE FIRST DAY OF THE INDEX CASE’S SYMPTOMS (you do not need to keep restarting the 14-day clock each time a person gets sick).

For those who have tested positive for COVID-19 and was admitted and discharged:

• They will be given specific advice on discharge so please ask the hospital doctors for this advice if you or a relative is been discharged. There will no point in calling the GP surgery for such advice because we will not know the answers.
• Do keep a record of people you have come into contact with and places you have visited, if you test positive public health workers will be contacting all those you have come into contact with.

NEW! Advice for vulnerable groups and over-70s Who are we talking about? High-risk groups

• Those are pregnant.
• Those over 70, regardless of any medical conditions.
• Those adults under 70 who qualify for a flu jab, which means:
• Long-term respiratory conditions.
• Chronic heart disease.
• Chronic kidney disease.
• Chronic liver disease.
• Chronic neurological conditions.
• Diabetes.
• After a splenectomy/sickle cell disease.
• Weakened immune system: HIV/AIDS, on steroids, having chemo.
• Severe obesity (BMI ≥40).

Very high-risk groups (more announcements on this group expected next week)

• Post-transplant.
• Those with cancer having active chemo/radiotherapy.
• Those with haematological cancers (at any stage of treatment).
• Severe chest conditions (CF, asthmatics who require admission/oral steroids).
• Severe diseases such as those needing dialysis.

What is suggested?

Social distancing: reducing interaction between people, this means:

• Avoiding contact with those who have symptoms.
• Avoiding non-essential use of public transport – if you have to use it, use it at less busy times.
• Working from home if possible.
• Avoiding large gatherings and gatherings in small public spaces (e.g. pubs, theatre, cinemas, and restaurants).
• Avoiding gathering with friends and family – use technology to keep in touch.
• Contacting essential services (GP, etc.) by phone/online means.
• Looking after your physical and mental health, despite all of the above!

For those living with vulnerable groups:

If someone in the household that a vulnerable person lives in gets COVID-19 symptoms, be particularly careful to follow the guidance on self-isolation within the home to minimise contact between the ill person and the vulnerable per-son as much as possible.

Coronavirus individual risk assessment for patients in the at risk group and their carers

We are receiving many requests from patients and their carers about their individual risks of contracting COVID-19 and disease severity if contracted. The following government website has the information about potential risks:

https://www.gov.uk/government/publications/covid-19-guidance-on-social-distancing-and-for-vulnerable-people/guidance-on-social-distancing-for-everyone-in-the-uk-and-protecting-older-people-and-vulnerable-adults

We are not able to offer risk assessment for each individual patients as this will impact on our ability to provide care.

If you employer insist on a piece of paper you can check your record online, print a list of your current problems and give this list to your employer hereby demonstrating that you or your loved one belongs to the at risk group. Totally asymptomatic individuals in the high risk group who wonder if they can go to work against the government’s advice will need to make their own risk assessment with their employer. We are unable to provide occupational health advice to patients and/or their employers. Some larger companies do have an occupational health service and you may be able to be risk assessed by them.

Sick notes or MeD3

It is inevitable that a number of employees may be required to quarantine themselves at home. In these cases, we will not be abIe to issue a sick note. We therefore expect your employer to be sympathetic if you are required to self-isolate for 14 days and to understand that the reason for this is to protect the welfare of your work colleagues and the wider community. We understand that you may also be able to call NHS 111 to request an email confirmation of the suspected Coronavirus diagnosis, to show to your employer if needed. Whilst we appreciate this may cause some difficulties between you and your employer, equally GPs have a responsibility to prioritise the assessment and management of the healthcare needs of patients who are acutely unwell.

The key messages are:

If you suspect you have any coronavirus symptoms (fever or new persistent cough):

• Use the 111 online coronavirus service to find out what to do next (it’s a few simple questions and then tells you what to do). Only call 111 if you are significantly unwell and cannot cope with your symptoms at home. 111 will pass a message on to your GP surgery if they think the surgery should contact you. You will then receive a call from the GP surgery.
• Do not go to a GP surgery, pharmacy or hospital.

NEW! Ibuprofen/NSAIDs and COVID-19

There are reports in the French press that ibuprofen may increase risks with coronavirus. PHE, in a statement to the Independent, says there is no published evidence that ibuprofen increases the risk of catching COVID-19 or of getting worse complications. The NHS medical director has advised in the interim, whilst we are waiting for research all those with confirmed or suspected COVID -19 infection should take paracetamol and not ibuprofen or any other NSAID medication. If you take NSAIDS for another condition for example arthritis and you have no symptoms of COVID – 19 you should continue to take your medication as usual.

NEW! What about ACE inhibitors/ARBs and COVID-19?

Those with comorbidities (including hypertension) are at increased risk of death from COVID-19 infections. There has been some speculation that ACE inhibitors/ARBs may further increase the risk of serious illness/death from COVID-19.

The European Society of Cardiology (and many other bodies around the world) has been quick to use a statement dis-missing this (https://www.escardio.org/Councils/Council-on-Hypertension-(CHT)/News/position-statement-of-the-esc-council-on-hypertension-on-ace-inhibitors-and-ang):

“Speculation about the safety of ACE-inhibitors or ARB treatment in relation to COVID-19 does not have a sound scientific basis or evidence to support it. Indeed, there is evidence from studies in animals suggesting that these medications might be rather protective against serious lung complications in patients with COVID-19 infection, but to date there is no data in humans.

The Council on Hypertension of the European Society of Cardiology wish to highlight the lack of any evidence supporting harmful effect of ACE-I and ARB in the context of the pandemic COVID-19 outbreak.

The Council on Hypertension strongly recommend that physicians and patients should continue treatment with their usual anti-hypertensive therapy because there is no clinical or scientific evidence to suggest that treatment with ACEi or ARBs should be discontinued because of the COVID-19 infection.”

Useful websites for patients:

Main advice to patients on NHS website: www.nhs.uk

The coronavirus symptom checker is available at: www.111.nhs.uk