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MARCH 13, 2020 -- A long time seems to have passed and a lot of things have changed since I last wrote about my perspective on the emergence of the coronavirus (COVID-19). It seems that hopes of the containment of spread of the disease are now gone and it has recently been declared a pandemic by the World Health Organisation. As each day has passed, the numbers infected and dying have increased and it has allowed us to gain more insight and become more concerned about the challenges that we are about to face.
The information available and the statistical analysis of the disease is rapidly evolving and there is understandably a time lag between reported infections and deaths as it takes time for the unfortunate victims to succumb to the disease. Some initial reports suggested that the mortality rate in Wuhan (where the virus was first detected) was 5.8% and the mortality in the rest of China was 'only' 0.7%. Which led to suggestions that giving health systems time to prepare may be associated with better outcomes. Obviously, there are other confounding variables here, including the Chinese state being able to put in place measures of quarantine that would not be so readily received in Western democracies.
I suspect I wasn't the only person to become much more concerned about the impending crisis once the details of COVID-19's spread and associated mortality rate in Italy began to appear. As of Wednesday, 11th March there had been 12,462 reported infections and more than 800 deaths, which equates to a mortality rate of 6.6%. Perhaps I had been falsely reassured (or possibly in denial) when first looking at the disease in China, which is after all, a very different health and socio-economic situation than we find in the UK, but Italy is much more relatable to us in the UK, although it does, statistically, have a much older population, with 23% of people being aged 65 or above.
The UK Government's plan can be briefly considered to be one of stages, with the country having already passed through the 'contain phase' which concentrated on measures to detect the disease early and isolate the known cases. We have now moved onto the 'delay phase' with a sombre Prime Minister making an admission unprecedented in my life time 'that many families are going to lose loved ones before their time' and that it was likely that although there were 590 confirmed cases, the true total was likely to be between 5000 and 10, 000 and that it is likely to spread much further.
The Government in England, unlike Scotland, has at this point not closed schools or banned any large public gatherings, and the English policy seems at odds with the rest of Europe, including in Ireland, which had a broadly similar infection rate to the UK, and has closed schools until 29th March. It seems that consideration of the disruption of school closures and social distancing measures is thought, at this stage, to outweigh any potential benefits. Closure of schools is a particular worry for many of us in the health service, as the childcare commitment will obviously put further strains on the NHS workforce, which will likely be struggling due to both confirmed COVID-19 infections and members of staff self-isolating due to respiratory symptoms eg, a persistent cough and high temperatures, for suspected COVID-19. It has been suggested that the population would suffer from coronavirus 'fatigue' if more extreme measures were put into place too early.
The figures suggest that the UK is 3-4 weeks behind Italy with regard the spread of the disease. It's apparent that the measures taken initially by China to slow down the globalisation of the disease, and the Government's containment phase, have bought the UK health service a little more time to prepare for the significant challenge that it will face. However it has faced criticism that this response and plan has not been aggressive enough and that time has been wasted.
Summer is the New Winter
If it's inevitable that the disease is going to infect a great number of the population, there may be those that question the need for these delaying tactics. The argument is that if we can only postpone the peak until summer, the NHS will be in a better position to cope with the increased demand as the usual seasonal illnesses will have passed. This may have been true previously, but years of austerity and funding policy that has failed to match increasing demand means that the UK goes into this crisis with fewer numbers of doctors per capita than most of Europe (2.8 per 1000 population) and fewer beds per head than most other developed countries (2.6 per 1000 population). Also it is well documented that the demand for emergency care no longer decreases in summer, and that recent emergency department (ED) summer performance against the national 4-hour standard has been worse than many winters and it has even been described as a year- round crisis
All of these measures have been taken in an effort to 'squash the sombrero' as the Prime Minister explained yesterday, which makes sense as the health care system will have a limited capacity and it may well be overwhelmed by the peak of the curve (or sombrero).
Some of us working in the acute settings are concerned and feel as though we are stuck on a railway track awaiting the on-coming train and are considering if we have used this extra time wisely. Certainly, plans have been put into place to increase hospitals' capacity for caring for ventilated patients, with plans to open up extra capacity in traditional Intensive care units and plans to care for ventilated patients in theatres and recovery, although staffing this demand may prove to be problematic. Emergency departments are having to put plans into place to identify and semi-quarantine/stream possible cases of coronavirus, and to care for those that require admission on separate wards whilst waiting for confirmatory tests, which can take up to 48 hours.
Trusts are looking at cancelling elective admissions and procedures, although this hasn't been carried out yet and most organisations continue to run with a worryingly high bed occupancy. Assurances have been given that organisations will have enough personal protection equipment for the staff, and many members of staff have taken the opportunity to expose long-hidden chins to the world and become clean shaven so that they can be appropriately clean shaven for fit-testing of masks.
Many of us have made plans for childcare for the inevitable school closures and have taken the opportunity to emphasise the importance of handwashing and some degree of social distancing for elderly relatives.
Dr O'Carroll points out he is an emergency medicine consultant, not an epidemiologist or virologist. He and his colleagues also politely ask people to stop stealing hand sanitiser from the hospital.