DISPATCHES FROM THE FRONT!
Peter Worlock provides us with some background to the current Covid situation.
Although my ‘day job’ is as an Orthopaedic Trauma Surgeon at the RVI, I am Clinical Director of Musculo-skeletal Services for the Newcastle Hospitals and have been heavily involved in managing the Newcastle hospitals response to Covid since last February. I cannot speak in detail about what is happening in the Northumbria and Gateshead NHS Trusts, but from talking to colleagues there I know they face similar problems to us in Newcastle.
Since late November, the number of patients with positive Covid tests (in both the city and the county) has been increasing rapidly and that increase has been particularly marked since mid-December. It is important to note that approximately 30% of people with Covid will have no symptoms. Most of these do not enter the testing programme, but they are still infectious. The situation has been made worse by the appearance of a mutation of the virus, which first appeared in SE England in late November/early December. This is now widespread throughout the UK. It is approximately 50% – 70% more transmissible that the initial virus, but the data so far does not suggest that it leads to more severe symptoms or cause more deaths. On the 30 December 2020, there were 36 Covid patients in the Newcastle hospitals. By the 6 January 2021, the number had risen to over 120 and is still rising.
During the winter months, the NHS is always under pressure from emergency admissions for stroke, heart disease and respiratory disease. This ‘winter surge’ began earlier and is much greater than normal this year, for reasons that are not immediately clear (the number of influenza cases remains low because of the higher than normal take-up of the influenza vaccine). There is now the ‘perfect storm’ of a bigger winter surge and the increasing Covid admissions. To create ITU and ward beds to deal with this, we have had to convert surgical wards to medical wards. ITU nurses are highly skilled and we have had to re-deploy anaesthetic and theatre nurses (who already have some of these skills) to staff these additional ITU beds. The lack of surgical beds and of operating theatre staff means we can only do a limited amount of in-patient surgery and the Newcastle hospitals have made investigating and treating cancer patients the main priority, as well as maintaining the emergency surgery service.
It usually takes 10 – 14 days from inoculation with the virus before symptoms develop (if symptoms are going to develop). During the second half of this incubation period, the patient is infectious and can transmit the virus to contacts. After symptoms develop, most patients recover over a 7 – 14 day period (and are infectious until symptoms have resolved). If the disease progresses and hospital admission is required, this usually occurs 7 – 14 days after the onset of symptoms. Of those who do not recover, the peak in the death rate is a further 10 – 14 days later. It is this natural history of the disease that leads to the ‘lag time’ of the effect of any intervention. It will be at least another week from now before we see any effect of the national lockdown, that started last week, on the number of positive tests, another three weeks or so before we start to see an effect on the number of hospital admissions and another 5 – 6 weeks before we see any effect on the death rate.
The ‘Get it right first time’ (GIRFT) group at the Department of Health has just produced its report on the best ways to treat patients with Covid in a hospital environment, after evaluating the data from the first wave. All UK hospitals will be ensuring they follow the best practice laid down. One of the striking things is that the main risk factors (in respect of the risk of dying from Covid) are increasing age, being male, obesity, diabetes, pre-existing dementia, severe liver disease and concurrent cancer. It was certainly our experience in Newcastle during the first wave that the majority of deaths occurred in patients with pre-existing health problems.
The virus spreads by contact between individuals. It can transmit either by droplets (aerosol) from the mouth and nose of a person with Covid landing directly on the mucus membranes (eyes, nose, mouth) of another individual or by the virus contaminating a surface, where it is then picked up on the hands of another person. If that individual then touches either their eye or their nose or their mouth with a contaminated hand, the virus can enter the body. This is the rationale for the ‘hands/face/space’ strategy. We know that frequent hand washing, using a face mask and maintaining a distance of two metres from other people reduces transmission rates. Within the hospital, staff have to go to work and there are Covid patients on some wards. On the Covid wards, full PPE is used. However, within the rest of the Newcastle hospitals we have maintained very low Covid transmission rates (reported as being amongst the lowest within UK teaching hospitals) by using that basic infection control policy. ‘Hands/face/space’ works, but has to be accompanied by restricting the contacts between individuals as much as possible – the data from throughout the UK shows that most transmission is within the home. You only need one positive individual to come into that household for as little as 15 minutes for transmission to occur throughout that household. The other key step in controlling spread of the virus, therefore, is not meeting with other people unless it is absolutely essential.
Whilst a successful vaccination programme is the long-term way out of this, it is a complex programme to organise and deliver. Whatever vaccine is used, two doses must be given to each individual. There are 65 million people living in the UK and even to offer vaccination to everyone over 18 years of age will need to 100 million vaccinations. The UK Government has ordered 120 million doses of vaccine. However, even if we manage to inoculate 2 million people a week (which will be no mean feat) it will take 50 weeks to vaccinate everyone in the UK over the age of 18 years. We will need to vaccinate 70% – 80% of the population, before there is ‘herd immunity’ within the population, so as to minimise spread. When offered vaccination, it is really important that everyone takes up that offer (whichever vaccine is on offer). Covid is never going to go away, but a mass vaccination programme (probably repeated regularly) is going to be the only way to maintain long-term control. Until the initial mass vaccination programme is completed, later this year, we have to maintain the infection control measures that are in place: ‘hands/face/space’ and meet with as few people as possible (including not mixing with members of your family who live in other households).
Your local hospitals are under huge pressure. As well as dealing with the Covid pandemic, we still have to deal with other medical and surgical emergencies, provide maternity care, treat trauma admissions and provide comprehensive cancer care. At one point last week, a 999 ambulance was arriving at the RVI Emergency Department every 1 – 2 minutes and ED came close to being overwhelmed.
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