Based on the information available to date
The document explains what we know about Coronavirus and how do we manage Coronavirus infection as a practice.
Coronaviruses are a broad range of viruses which, at one end of the spectrum, cause the common cold, at the other end, cause potentially fatal diseases such as MERS and SARS. This new virus is named SARS-Cov-2; the condition it causes is COVID-19. DNA analysis shows it is closely related to SARS and similarly evolved from an illness affecting bats. As we all know, this then spread in Wuhan, China, and subsequently worldwide. However, the speculation it was initially transmitted from zoonotic sources in a seafood market in the city has not been confirmed. SARS-Cov-2 has been isolated in at least 66 countries around the world. One can speculate that where countries have no cases, this may be due to a lack of testing rather than truly escaping the condition.
There remains uncertainty about the mechanism of spread. Human-to-human transmission is now undisputed, although the degree of infectivity is still uncertain. The virus is predominantly respiratory droplet spread among close contacts (e.g., within 2m) for prolonged periods of direct contact with infected secretions (the virus has been isolated in most bodily secretions including faeces – time to close that lid when flushing…). It can survive on surfaces outside the body, although for how long is unclear – it is assumed to behave like other coronaviruses, which can last for hours to several days depending on the conditions.
The average incubation period is 5-6 days, but it is very variable and can range from 1-14 days. People are infective when symptoms manifest. Currently, there is no data on patients transmitting the disease without symptoms, although viral shedding has been found in the 1-2 days before symptoms, for up to 2 weeks in respiratory samples, and 4-5 weeks in faeces. The significance of this shedding regarding infectivity is currently uncertain.
What are the clinical features?
The main features are fever, cough or chest tightness, and dyspnoea. However, a paper published in the BMJ shows that patients may well have none of these – fever was present in 77%, cough 81%, fatigue/myalgia 52%, headache 34%, diarrhoea in 8%. This was in patients admitted to the hospital, so many in the community may have minor symptoms only and none of the above.
This will make it impossible to distinguish between Coronavirus and ‘normal’ infections.
Indeed it appears that 80% will have mild symptoms (or none), 15% will be severely unwell, 5% critically unwell.
The most at risk are the elderly (particularly >80yo), and those with significant co-morbidity.
Interestingly children appear to be rarely affected, although it is still possible for them to be seriously ill and not clear whether asymptomatic children can still be vectors for disease. Pregnant women were high risk during the swine flu outbreak, but so far, this hasn’t appeared to be a particular issue for COVID-19.
It is thought to be around 1-2%, some reports have suggested slightly higher but this is likely to be biased through testing of mostly high-risk individuals. Given there appears widespread transmission in the community the number of proven cases will be an underestimate of true disease (although we don’t know by how much) and the real case fatality rate is presumably lower.
Recommendations on testing have changed in the UK since March 10th.
Any patient requiring hospital admission and either:
Clinical or radiological evidence of pneumonia, ARDS, or influenza-like illness Patients who meet both epidemiological and clinical case criteria, either well enough to remain in the community or who get admitted to hospital.
Epidemiological criteria: travel to specified countries and areas (click here for list), including transit for any length of time, or contact with confirmed cases of COVID-19 – both within the last 14 days – AND
Clinical criteria: acute respiratory infection of any degree of severity, including at least 1 of SOB or cough, or fever with no other symptoms
‘Contact with a case’ for testing is now defined as:
Living in the same household, or Direct contact with the case or their bodily fluids or lab specimens, or in the healthcare setting, being in the same room when an aerosol-generating procedure is undertaken without appropriate PPE or
Direct or face-to-face contact with a case for any length of time, or
Being within 2m in any other situation for >15mins, or
Being advised by public health that contact with a confirmed case has occurred.
Testing is predominantly with PCR and only available is specific laboratories. Nose and throat swabs, plus sputum if possible is preferred.
Turn-around time is suggested to be 48h, although in practice most patients have a result within 24h.
We don’t have figures on the sensitivity and specificity, but in general, PCR is considered very good, especially for negative results. Confirmed cases who are hospitalized may have serology.
If/when testing is performed routinely outside of the reference labs the result is considered presumptive and then needs further confirmatory testing in the reference lab, but that patient should be treated as a confirmed case until proven otherwise.
What seems unclear is at what point a test becomes positive. At the point of symptoms, there will be plenty of viral shedding and the test should be accurate, but can a negative test be relied upon is a high-risk patient is asymptomatic but still in the incubation period?
What should we do with high-risk patients who test negative?
Patients with travel to a category 1 country/area need to continue to isolate until 14 days after leaving the country. Patients with travel to a category 2 country/area need to continue to isolate until 14 days, or their
symptoms resolve, whichever is shorter. For contacts of a proven case, they need to continue to isolate until 14 days after the contact.
If any of these groups develop new symptoms in the meantime they should contact 111 for re-assessment. The test will be repeated.
Whilst a range of treatments such as antiretrovirals for HIV and Ebola, oseltamivir, and more complex ICU-based interventions are being tested, at this point, supportive therapy is the best known possible treatment.
Vaccines have already been produced, which is absolutely remarkable, but require human testing, ideally RCTs, and are unlikely to be widely available (assuming they work and don’t have nasty side effects) until 2021.
Lead: Dr. Sumit Sharma and Mrs. Kerry Meachen
What are we doing at Brockhurst Medical Centre?
There is specific guidance set out by PHE in the Special Operating Procedures document which needs to be digested and acted upon.
There are several elements to protecting our patients and ourselves.
Identify high-risk patients via telephone prior to them attending the practice and signpost them to 111 to be assessed.
Ask any patients requesting appointments about relevant travel or case contact history
It may be wise to manage as many people remotely as can be done safely regardless of risk assessment.
We should have put patient information posters up to be visible before patients enter the building, at reception and online book-in, in waiting areas and clinical areas.
All patients presenting at reception should be asked relevant questions to assess risk
Have you been to any category 1 area in the past 14 days or a category 2 area in the past 14 days and have cough, fever, or SOB?
Have you been in close contact with someone with confirmed Coronavirus?
Have you been asked to self-isolate?
If YES to any of the above, the default is to ask the patient to return home and call 111 immediately.
If they are too unwell to do this, they should be isolated in your designated isolation room at the practice and asked to contact 111 explaining the situation.
If they need medical assessment or intervention while this is undertaken, use personal protective equipment.
If they become critically unwell, call 999 and inform them about the COVID-19 concerns.
If patients with suspected COVID-19 attend the practice, leave the room when this becomes apparent, isolate the patient in Room 5, contact the local ID team, decontaminate yourself and then deep clean the room. Avoid the place until this is completed.
Encourage good hand hygiene in patients and staff attending the practice to reduce the risk of cross-contamination.
Appropriate use of personal protective equipment for confirmed cases where contact is unavoidable.
Room 5 has been identified as a dedicated room for isolation, DE clutter it to facilitate cleaning, and have easy access to PPE. We will need to know how to decontaminate ourselves and rooms.
Meanwhile, it has been suggested to the public that “social distancing” may be helpful. This might include avoiding visiting care homes, large scale events, etc. There is the possibility that schools, universities; even businesses may be shut temporarily.
A similar premise could be adopted in primary care using telephone triage for all appointments, only bringing those who need a face to face review down to the surgery. This is commonplace in many practices anyway to try to improve waiting times and workloads.
In primary care, we have been given simple surgical masks, providing a barrier (they are not airtight) to virus-containing droplets.
Experts have used modeling data and the situations in Wuhan and northern Italy to try and build a picture of how the infection will spread but nothing is certain. The main points:
It is likely to spread with escalating numbers of cases. The number of cases is expected to increase rapidly over the next few weeks. The duration of the outbreak is unclear, but we will probably see high numbers of cases for several months. Slowing the rate of increase is helpful to ease winter pressures on health services, to allow time to build resources such as testing kits, protective equipment, etc., and to spread cases over a more extended period.
Lessons can be taken from the Chinese governments’ management of the situation, with a large scale, very restrictive lock-down. While extreme cases in the country are now falling and wide-spread transmission throughout China appears to have been prevented. Italy appears to have gone in the same direction.
We would continue to update this page and social media as Government advice changes.
Dr Sumit Sharma