What we are learning about COVID19 and those most at risk

What we are learning about COVID-19 and those most at risk

We asked The George Institute’s respiratory expert Professor Christine Jenkins about what the latest data on COVID-19 is telling us, particularly in relation to high risk groups.

What are we learning from China about how the virus is behaving? 

We’re learning a great deal about the clinical illness as papers from Wuhan are published, describing the pattern of COVID illness in large numbers of patients, every week now in the leading medical journals. The most obvious public health learning from China is the value of lockdown, which was implemented later than would have been ideal, but was highly effective in Wuhan. Despite the rapid rise in the number of cases, patients admitted to hospital and deaths, it achieved a rapid reduction in deaths and subsequently a dramatic fall in the number of new cases over a period of only six to eight weeks.  Several papers have since been published which clearly indicate that increasing age is a risk factor for death from COVID-19, although people can die at any age.  Further, it is obvious that coronavirus is quite different to the influenza virus in several key ways.  It is more infectious but it does not appear to infect children at a high rate, which is most unusual for a respiratory virus.  The majority of transmissions are therefore from adult to adult, in a roughly 1:2 ratio (i.e. one infects two others). The lockdown in Wuhan placed a limit on the extent to which other parts of China were affected although it still remains perplexing that the virus did not seriously affect most of the rest of the population in other parts of mainland China. Many questions remain unanswered, in particular how much very mild illness occurred and therefore the size of the “Denominator” – all the people infected with virus. Only when we know this number can we say what the true death rate is from coronavirus infection.

How are people with existing respiratory conditions responding? 

People with existing respiratory conditions usually experience a greater level of symptoms when they have a viral respiratory infection. This is not surprising as they may already be symptomatic from the disease already affecting their lungs, whether it be asthma, COPD or pulmonary fibrosis. On the other hand, a critical question for these people is whether they are more vulnerable to catching the virus or to having a life-threatening consequence from infection.  At this stage it does not appear that they are more vulnerable to catching the virus, but are more vulnerable to serious outcomes from it. There is a very high rate of smoking amongst Chinese men in particular, but at present smoking has not been identified as a risk factor for getting COVID.  As well, the prevalence of smokers amongst people who died from coronavirus in China was no higher than the prevalence of smoking in the general population.

Tell us more about the reported cases of relapse into pneumonia? 

In some people the virus causes a very rapid progression from the onset of symptoms such as fever and cough through to the development of pneumonia, which is usually evidenced by marked breathlessness and low oxygen levels. The pneumonia caused by coronavirus can cause respiratory failure, when the lungs cannot supply adequate oxygen levels to the circulation and vital organs. This can worsen rapidly over a few hours, progressing to a requirement for intensive care admission and assisted ventilation.  In other patients there is a slower evolution of the symptoms and the initial coronavirus symptoms may be mild with a fairly typical illness which lasts three to five days and then appears to improve. Subsequently a few days later some people can deteriorate with pneumonia and respiratory failure.

What does the course of the disease look like in these people and how can they be identified? Is this just in the elderly? 

No, this is definitely not just in the elderly.  Although older people (by which we mean over 60), particularly those with chronic ill-health and comorbidities (such as diabetes, hypertension, lung and heart disease) are more vulnerable to dying from COVID, people can die at any age.  The reasons why somebody who is fit and healthy in their 30s or 40s can die from COVID remains unclear. There may be a constitutional vulnerability to severe effects of viral infection, or alternatively it may relate to the dose of virus they received when they first were exposed.  We have yet to explore the reasons for this in full.

What is your advice to people with existing respiratory conditions? 

People with pre-existing respiratory disease should see their doctors to make sure they are taking the right treatment, receiving their vaccinations, maintaining physical activity and looking after themselves as best as is possible.  This is particularly important in people aged over 60, and in all patients with asthma who tend to be rather relaxed about their preventer treatment if they are feeling well.  It is far better to control asthma well with daily preventer medication than to be vulnerable to a sudden attack when you develop a viral infection.  It is also important that people with asthma use a puffer and spacer to take their reliver medications, rather than nebulisers, as these can spread infection.  They should also ensure they have a written action plan to use in the case of any deterioration. I would encourage all patients with asthma and COPD to discuss their action plan with their GP and make sure they are on the right treatment. Finally but most critically, everyone with lung disease should be taking great care to reduce their risk of coronavirus infection, maintaining hand hygiene and social distancing as advised by health departments.

 

handwashing

Masking the unmasked - Protecting Front-line health workers during the COVID 2019 pandemic

The George Institute for Global Health, India in its recent rapid evidence synthesis has pointed out that the Frontline Healthcare Workers are at increased risk during COVID-19 even in the course of their normal activities and should be provided with personal protective equipment. The World Health Organisation also has outlined a series of basic protective measures for the frontline health care workers (FLHW) who are at the forefront of fighting the COVID-19 pandemic. This includes protecting oneself and those who come into close contact with others in the community as well. 

However, masks and other personal protective equipment are in short supply in many rural and urban parts of the country and this may put the work of FLHWs at great risk especially when they come into contact with community members. Many frontline health workers confirm this from ground zero. Though this is largely anecdotal, it still underscores the need for the government to be prepared for providing adequate PPE to the FLHWs, a recommendation which the rapid evidence synthesis makes.  

“While working with communities in and around Ballabgarh in Haryana, we noticed that none of the field staff or ASHA worker in the villages had medical masks. It is also not available in local pharmacies,” said Amanpreet Kaur, Research Fellow, The George Institute India, adding the field staff told her that there were few places where they found medical masks, but prices were too high (five times the original price), and the same goes for sanitizers (4-5 times higher price than original).

The situation seems to be no better in villages in and around Palasa in Andhra Pradesh.

“No masks are available in shops and even in the community health centre in Palasa, there seems to be a shortage of masks and aprons,” said Dr Balaji Gummidi, Senior Project Manager, George Institute for Global Health, India who leads a project in Uddanam area of Srikakulam district.

The local administration is aware of the fact that there is scarcity of PPE, he adds.

A similar situation is seen in Vijayawada or in Rohtak.

“It is really heartening to note that the Ministry of Health and family Welfare has come up with guidelines on PPE. We hope that this will ensure that basic personal protective equipment like masks or hand gloves are available in sufficient numbers for the frontline health workers or the health care providers during this hour of crisis,” says Prof Vivekanand Jha, Executive Director, The George Institute India.     

The recently conducted rapid evidence synthesis by a team of researchers from the George Institute India has revealed that FLHWs will be at increased risk of COVID-19 even in the course of normal activities.

“My observation, based on short visits, is consistent with this finding. I can’t but agree with the recommendation that the availability of these life-saving items should be accompanied by training on proper usage in the early phases,” said Amanpreet

These finding acquire an urgent tone, since frontline health care are the backbone of our health activities and cannot practice physical distancing because of the nature of their jobs. It becomes a responsibility of the healthcare system to provide them with appropriate and adequate protection.  

Frontline health workers at increased risk of COVID-19 and stigmatisation

Media release

Front Line Health Workers (FLHW) will be at an increased risk of COVID-19, even in the course of their normal activities.  Therefore, it is essential to provide personal protective equipment (gloves, surgical masks, hand sanitisers; N95 masks if involved in contact tracing) in adequate quantities. This should be accompanied by training on proper usage in the early phase itself.

Using technology-enabled solutions to screen and manage mental health care – implications for managing other health conditions like COVID 19

Media release

Even as the nation battles the novel corona virus pandemic and the mental health challenges it poses including escalation of anxiety and panic in both urban and rural areas of the country, a new study by the George Institute suggests that technology enabled mental health care service delivery improves depression and anxiety symptoms especially in low and middle-income countries like India.

Persons with kidney disease and on haemodialysis advised to follow guidelines to mitigate risk of COVID-19 infections

Media release

The COVID-19 pandemic is throwing up unique challenges for health systems. It presents particular challenges for patients who receive regular haemodialysis. These patients with damaged kidneys, also known as uremic patients, are particularly vulnerable to infection and may exhibit greater variations in clinical symptoms and infectivity.