Here’s the role antibody tests can play in the UK’s lockdown exit strategy 

“…antibody tests – even if they lack some sensitivity – can be used to estimate what proportion of the population has already been exposed to the virus. This is really helpful in telling us whether there is likely to be widespread immunity in the population and thus how likely there is to be a second wave of infections (and how big that wave might be), once the social-distancing measures are relaxed. These tests would be carried out in a laboratory and could be scaled up very easily…..”

“Public Health England’s laboratories at Porton Down are reportedly making very good progress with this population-level testing, raising hopes that useful data may be available soon.”

Eleanor Riley is professor of immunology and infectious disease at the School of Biological Sciences at the University of Edinburgh www.theguardian.com

How do we return to some semblance of normality without risking a second wave of severe disease and death? Two weeks after lockdown began, discussions are moving towards the prospect of an exit strategy. There is no rule book for this – it has never been done before in modern times – but some are pinning their hopes on large-scale testing to enable this. Is this realistic, and if so how will it work?

There are two basic types of test: tests for the virus itself (swab tests that look for current infection) and tests for antibodies to the virus (blood tests that indicate prior infection). In the past few weeks in the UK we have carried out swab tests on people who are ill enough to be admitted to hospital. Yet many less severe cases of coronavirus are going undiagnosed, so we don’t really know how many people have been infected. We also don’t know if these people are immune to reinfection, or for how long.

Countries such as South Korea have used the swab test to identify all cases (not just the severe cases that are admitted to hospital) and then traced and isolated all the people they have been in contact with. This approach relies on a very large capacity for running swab tests, and a population ready to present for testing as soon as symptoms occur, and adhere to strict observation of self-isolation rules. Scaling up swab-testing in the UK has been problematic and although it will undoubtedly improve as the infrastructure gets better, and new and faster tests are introduced, waiting until we have the capacity to test and contact-trace all suspected cases may mean many more weeks of lockdown.

Antibody tests can be used to find out whether someone who had symptoms but was not swab-tested at the time did indeed have the virus, or whether their symptoms were due to something else. These tests are best done three or four weeks after the initial onset of symptoms, when the majority of people will have developed detectable antibodies. The tests can be carried out in designated laboratories or provided as simple kits for self-testing. The government has discussed the purchase and validation of self-testing kits, and floated the idea that a positive antibody test might lead to the issuing of some kind of immunity certificate. However, we don’t yet have a reliable test and we won’t know for some time whether antibodies predict immunity to reinfection, or for how long.

There seem to be two problems with the self-testing kits. The first is lack of specificity: people who have not been infected with the virus giving a false positive result (most likely due to having antibodies to closely related coronaviruses, but not the one that causes Covid-19). The other is people who have been infected giving a false negative result (possibly because they have very low levels of antibodies, as seems to be the case with people who have had very mild symptoms). Both are obviously problematic and would mean that individuals could not rely on the test to inform their own personal risk or behaviour. Whether highly sensitive and specific self-testing kits will be available in time to inform our exit strategy is unknown.

Perhaps more usefully, antibody tests – even if they lack some sensitivity – can be used to estimate what proportion of the population has already been exposed to the virus. This is really helpful in telling us whether there is likely to be widespread immunity in the population and thus how likely there is to be a second wave of infections (and how big that wave might be), once the social-distancing measures are relaxed. These tests would be carried out in a laboratory and could be scaled up very easily. In this case, as long as the test is highly specific for the Covid-19 virus and we know roughly what proportion of true positives it detects (does it miss half, one in five, one in 10?), we can use the data to model how widely the infection is likely to have spread.

If population-level antibody testing suggests that, say, half of the population has already been infected, relaxing of the social distancing rules is less likely to lead to a second wave of serious infections than if only one in 100 has been infected. Public Health England’s laboratories at Porton Down are reportedly making very good progress with this population-level testing, raising hopes that useful data may be available soon.

In the meantime – given the current absence of population-level antibody data or nationwide test-and-trace capability – a combination of a gradual relaxing of the lockdown, monitoring the impact of this on hospital admissions and continued shielding of the most vulnerable may be our best bet.

 

Plasma from coronavirus survivors found to help severely ill patients

Doctors have found tentative evidence that seriously ill coronavirus patients can benefit from infusions of blood plasma collected from people who have recovered from the disease.

Ian Sample, science editor  www.theguardian.com

Two teams of medics working at separate hospitals in China gave antibody-rich plasma to 15 severely ill patients and recorded striking improvements in many of them.

In one pilot study, doctors in Wuhan gave “convalescent plasma” to 10 severely ill patients and found that virus levels in their bodies dropped rapidly. Within three days, the doctors saw improvements in the patients’ symptoms, ranging from shortness of breath and chest pains to fever and coughs.

Xiaoming Yang, from the National Engineering Technology Research Center for Combined Vaccines in Wuhan, described the treatment as a “promising rescue option” for severely ill patients, but cautioned that a larger randomised trial was needed to confirm the findings. Details of the pilot study are reported in Proceedings of the National Academy of Sciences.

Another team of doctors led by Lei Liu, from Shenzhen Third People’s hospital, gave convalescent plasma to five critically ill patients. All showed improved symptoms after the infusions and within 10 days, three patients were able to come off the ventilators that had been keeping them alive, according to a preliminary report in the Journal of the American Medical Association.

The findings raise hopes that donated blood from recently recovered patients could be used to boost the immune systems of more vulnerable people and help them fight the infection. But with only a small number of patients so far treated with plasma, and the infusions given outside of formal trials, it is impossible to know how much benefit the treatment really brings.

Convalescent plasma treatments date back to before the 1918 Spanish flu pandemic. The therapy relies on the fact that people who have recovered from a viral infection have antibodies in their blood that can rapidly detect and destroy the virus the next time it attacks. Infusing the plasma into patients, and potentially into people at risk of being infected, can boost their immune systems and potentially provide protection.

Hints that the therapy may help have prompted US doctors to trial infusions in the outbreak in New York and similar studies are expected to start in the UK in the coming weeks. Britain’s national blood service has begun screening blood from patients to find plasma rich in antibodies to use in those trials.

Professor David Tappin, a senior research fellow at the University of Glasgow, has applied to the UK’s National Institute for Health Research to run two clinical trials with convalescent plasma. They will look for evidence that plasma can protect frontline workers from infection, prevent patients from deteriorating and needing ventilation in intensive care units, and improve the condition of those who are already severely ill.

Tappin said the cases reported from Wuhan were important because they suggested that giving plasma to severely ill patients appeared to be safe. “The outcomes are also encouraging for these patients,” he said. But he added that to be sure plasma improved on the natural course of the disease, and that it was safe in larger groups of patients, formal trials had to take place.

Professor Munir Pirmohamed, the president of the British Pharmacological Society, echoed the need to be cautious about the Wuhan cases. “This was not a randomised trial and all patients also received other treatments including antivirals such as remdesivir, which are currently in trials for Covid-19,” he said.

“It is also important to remember that there are potential safety concerns with convalescent plasma, including transmission of other agents and antibody enhancement of disease,” he added. “Even if shown to work, scalability to treat large numbers of patients may become an issue.”

 

Leadership matters. Who is in charge?

When Devon and Cornwall Police declared a “major incident” in response to the coronavirus epidemic on 20 March, Owl dared to ask the questions, locally, who is in charge, who takes control? There appears to be no clear answer. The official line is: No single responding agency has command authority over any other agencies‘ personnel or assets. Where multi-agency co-ordinating groups are established to define strategy and objectives, it is expected that all involved responder agencies will work in a directed and co-ordinated fashion in pursuit of those objectives.

Today Owl reports that Devon and Cornwall Police have advised EDDC on the need to close some car parks. Our proto-devolution body Heart of the South West (HotSW) covers Devon and Somerset (and has remained silent, apart from fret about the economic impact). The geographic county is administered by two autonomous unitary authorities: Plymouth and Torbay; and Devon County Council – so no single voice. How the NHS, Quality Care Commission and Public Health England are organised hierarchically in Devon is a bit of a mystery to Owl. Perhaps the most coordinated action has come from the local MPs when they backed the “please come back later” campaign, but it was far from unanimous. 

This article discusses the issue at National level.

With Boris Johnson in hospital, government is adrift 

Boris Johnson is ill and in hospital. That must be wretched for him and his family. We can only wish him well and a speedy recovery. His infection by Covid-19 indicates the extraordinary contagiousness of this disease and possibly its widespread prevalence. Of the first there is now no doubt. Of the second, without testing, there is no clue.

That a prime minister is ill is a serious matter. Yesterday the Queen performed her duty as the nation’s figurehead with remarkable assurance. In clear, undramatic language, she spoke free of cliche and with sincerity. Her few words of hope shone through the darkening forest of the media coverage of these events. It was the first time I smiled at the television in a month.

A prime minister too is a figurehead, but has a harder task. Johnson is the nation’s elected leader at a time of crisis, with millions reliant on his decisiveness, judgment and public demeanour. At least one cabinet minister maintains that these qualities can be deployed from his hospital bed. Sometime soon, that idea will become absurd. It presents the government machine as a driverless car which, in the style of Yes Minister, will perform equally well, if not better, with no politician at the wheel. Leave the experts and “the science” to get on with it, and all will be well.

Rumours abound that since the start of the coronavirus outbreak, this machine has been ramshackle. The nation’s health services, so proudly championed for so long, were unprepared both centrally and locally. This was despite trial runs and forewarning. It does not matter who was to blame. The system malfunctioned. Then in mid-stream the cabinet reversed its policy from mitigation to suppression. Ministers ran in and out of Downing Street press conferences, making pledges, setting targets and micro-managing social distancing. Little of what they said carried full conviction.

Suddenly, leadership mattered. Who was in charge? Johnson’s initial glib Churchill imitations (the Queen wisely chose Vera Lynn) had to change, and they did. As Johnson fell ill, news conferences were conducted by the dull, steady Dominic Raab or the flashy, impetuous Matt Hancock. Experts came and went, spurring debate as to what side they were on.

Government lurched into lecture mode. It began telling people not to work, how to shop, and where and with whom to walk. These are not the normal actions of government in a free society. They are painful and massively intrusive on daily life. They are also being taken by ministers and officials amid extremes of risk and uncertainty. The instinct under pressure was not to welcome argument or accountability. It was to demand obedience.

That is not enough. At the very least the use of such powers requires the most explicit public leadership. Bluntly, they need the qualities of communication for which Johnson was supposedly elected. They also need ready scrutiny and challenge, which is currently being supplied only by the media. Parliament has abandoned what should be its primary role: holding executive decision to account. The new Labour leader, Sir Keir Starmer, was therefore right to refuse Johnson automatic support.

The cabinet cannot operate with half its members in varying degrees of isolation. The wonders of Skype and Zoom cannot replicate the cut and thrust, the body language, the public and private exchanges of a truly deliberative forum. There has to be a conductor knowing when and how to bring the instruments of government into play. There has to be a boss.

Past experience of sick leaders is not happy. Churchill’s doctor, Lord Moran, and his wartime aide, Lord Alanbrooke, related the impact his clinical depressions had on war cabinet morale. The same message came through the 2008 study of sickness in power by the former foreign secretary, David Owen. He traced the hubristic impact that power can have on those who wield it, not least a refusal to believe they might be ill.

Democracies vote for leaders, not anarchists. Every leader’s style is different. Attlee could hardly have been less like Churchill, Heath less like Thatcher, Brown less like Blair. All depended on their close relations in Downing Street with advisers and cabinet colleagues – and suffered when these broke down. Johnson decided from the start that he would not harbour critics in Downing Street, preferring the second rate to the second thought. He made his own indispensability a feature of his rule. In normal times, that is unwise. In a crisis it is stupid.

Britain’s present predicament is yielding lessons aplenty. One is that the formal machinery of government matters. Johnson’s response to coronavirus has been to nationalise, standardise, command and control everything. In his lockdown, one rule must fit all. Such is Britain’s centralist constitution. But if so, it must depend on one thing: efficient and accountable leadership. At present the prime minister is clearly unfit. A public and functioning alternative must surely be in place.

Hotels being pressed into use to replace what used to be Community Hospitals

Two examples from Devon and Dorset:

Exeter hotel opens its doors for former patients and NHS staff

Anita Merritt  www.devonlive.com 

An Exeter hotel which closed this week due to the coronavirus lockdown is being converted to accommodate hospital patients who are awaiting care home placements, as well as new frontline staff.

Hampton by Hilton, which is located by Exeter Airport, closed on Tuesday following latest government advice to reduce the spread of Covid-19.

On Friday, it announced on its Facebook page that the hotel was getting ready to support the NHS and Devon County Council.

Today the council has confirmed the hotel is being utilised to help ease the pressure on local hospitals and care homes who are attempting to cope with an increase in demand on its services, while also trying to recruit frontline staff.

A spokesperson for Devon County Council said: “We are currently working on a number of potential options around Devon for creating additional residential care facilities for those with health and care needs being discharged from hospital in case existing care home capacity becomes insufficient.

“We are also planning to accommodate extra staff currently being recruited and redeployed into frontline health and care roles. More information on these arrangements will be given in due course.”

On its Facebook page the hotel said on Friday: “The team are now busy getting the hotel set up in support of the #nhs#repurposed#supportingthenhs#Exeter#Devon#SouthWest ❤️ #staysafe#stayathome#staystrong.”

Yesterday the hotel reported the moving of specialist beds into the hotel has begun.

It has not been confirmed when the hotel will open in its new capacity. [29 March]

Hotel opens as ‘social care’ hospital for non-coronavirus patients – helping NHS in Covid-19 battle

www.dorsetecho.co.uk

A Weymouth hotel which has been turned into a hospital unit has started receiving its first patients yesterday. [6 April]

As part of the efforts to help people get out of hospital when they are fit to do so, a new model is being launched in Dorset with the Best Western Hotel Rembrandt on Dorchester Road ‘repurposed’.

It will offer 31 beds for people who are leaving hospital for reasons not related to coronavirus.

It will be used as a social care base for people who can’t go directly back to their own homes when they are medically fit to leave hospital and are waiting for a social care help and support package to be put in place.

It offers more capacity to the health and care system across the area, keeping hospital beds available to support people with coronavirus.

As the hotel-based care offer is not an extension of a hospital stay for medical reasons, it’s not appropriate to use other hospital settings, such as community hospitals, Dorset Council says.

It is being staffed by Abi Live-In Care and a call system, has been installed to assist people at the facility throughout the day and night. Mobile phones and tablets have also been provided to help people keep in touch with friends and loved ones.

Cllr Laura Miller, Portfolio Holder for adult social care and health at Dorset Council said: “This a great success, showing the dedication of partners across the system to get this set up in just a few days. We’re hearing nationally about the shortage of hospital beds, and we want to be ahead of the curve by providing alternative solutions for people who are medically fit to leave.

“We can then make sure that the most critically ill people have access to the right help and support in hospitals at the right time.

“We also know that care and support in people’s homes is becoming increasingly difficult to find, so this hotel-based care provision will make sure anyone who can leave hospital can do so in a safe way, while we work with them to get the support they’ll need to return home.”

Admissions to the Hotel Rembrandt will be built up gradually over the coming days. Dorset Council and Abi Live-In Care staff will monitor the progress carefully and will build a better picture of the situation throughout the week.

The Grange Hotel at Oborne near Sherborne will be the second base to open offering support for people in the north of the county. They will be taking admissions from Monday, April 13.

 

‘Police advice’ prompts closure of two Exmouth car parks and Seaton site

District council bosses have shut a pair of Exmouth car parks – and another in Seaton – during the coronavirus pandemic on the advice of police. 

East Devon Reporter  eastdevonnews.co.uk

East Devon authority chiefs say the move has been made to ‘reinforce’ the Government’s social distancing advice to stop people driving to beaches and beauty spots.

They have closed the Maer Road and Foxholes sites in Exmouth and Seaton’s Jurassic long-stay facility.

This action has been taken to reinforce the clearly-stated government advice on social distancing, staying at home and not driving to beaches and beauty spots…

An East Devon District Council spokesperson said it had made the decision ‘on the advice of police’.

They added: “This action has been taken to reinforce the clearly-stated government advice on social distancing, staying at home and not driving to beaches and beauty spots.

“All other car parks currently remain open but are under review.”

 

Fears that Britons self-isolating with Covid-19 may seek help too late

Owl wishes Boris Johnson a full and speedy recovery. This is an anxious time for his family and for the Nation. 

The Prime Minister’s case highlights the need for everyone self-isolating with coronavirus symptoms to seek medical advice if their symptoms persist. This advice has not been as clear as it could have been, as this article explains.

Kate Connolly  www.theguardian.com 

Concerns are being raised that people isolating at home with worsening Covid-19 symptoms may not call for medical help early enough when they enter the second, more severe, phase of the virus, possibly reducing their chances of survival.

The NHS does not have a proper monitoring system for those suspected of having coronavirus, said Dr Bharat Pankhania, a senior clinical lecturer at the University of Exeter medical school.

“If a patient is developing pneumonia, it can get progressively worse very quickly and hence early admission upon the first signs of difficulty with breathing are very important,” he said.

“It is important for people recovering at home that there be a monitoring system in place too. Something that we have thus far not introduced.”

There is a danger that people will arrive in hospital only when their symptoms are very severe, with more of a risk that they will end up in critical care and possibly die, he said.

The early symptoms of mild disease are a persistent dry cough, a raised temperature and shortness of breath. The advice to anyone with those symptoms is to self-isolate at home. They are not told to inform the health service.

Most people recover within a week, but if their symptoms worsen or they still have a high temperature at the end of that time, the instruction is to fill in a form on the NHS 111 coronavirus website if they can – and to call NHS 111 only if they cannot do that. Depending on their answers, they may get a visit from a doctor or be admitted to hospital.

Covid-19 is said to be mild to moderate in 80% of people, but can cause viral pneumonia. In the most serious cases, the immune system fighting the virus overreacts. If that happens, what is known as a cytokine storm attacks their organs. The individual will need ventilation in hospital to take over their breathing and possibly mechanical support for their heart, liver or kidneys.

People with symptoms at home will not get medical help unless they ask for it, unlike in some other countries, which have testing for people with symptoms and monitoring for them while at home.

Health authorities in the southern German city of Heidelberg have introduced a “corona taxi” service, which allows medical personnel to visit patients with the virus at home and assess their progress. This was introduced after virologists and other doctors recognised that it often comes in two waves and that typically on the eighth day, patients’ health can take a turn for the worse.

Patients with confirmed infections or suspected to have coronavirus are being called on a regular basis by student doctors manning phone lines, and based on their accounts, a taxi crew can then arrange to visit them.

Four of the taxis – small buses usually used for school runs – are constantly travelling around the city visiting patients.

“These daily phone calls and house visits would totally overwhelm the doctors here,” said Uta Merle, a medical director for gastroenterology and infections at Heidelberg University hospital, which is why medical students are being drafted in. Eight hundred have so far volunteered.

Hans-Georg Kräusslich, the head of virology at the hospital, told Frankfurter Allgemeine Zeitung the visits are necessary because “often patients don’t have the courage to ring up the clinic and don’t actually take their worsening state seriously”.

Thanks to the taxis, he said, “our colleagues have discovered quite a few patients who they were able to protect from a drastic worsening of their conditions”.

Many have been brought into hospital and put on ventilators as a result. That crucial move made just in time is believed to have saved many lives in Germany. The taxi crews have received letters of thanks from patients, crediting them with saving their lives.

Pankhania said people in the UK are no longer going to hospital for conditions other than Covid-19 in the sort of numbers that would be expected. “For whatever reason, we have frightened off the patient. Those things we should be seeing are not turning up. These people are soldiering on,” he said.

He has himself heard of cases where people were very sick with symptoms resembling those of Covid-19, but did not seek medical help and died at home.

He said it was possible that some people were put off from calling NHS 111 when their symptoms worsened or if they still had a fever after a week – which are the first clues that their condition may be becoming severe.

He also does not think it is satisfactory for people with symptoms not to be tested. “I don’t think that is good enough,” he said. “I used to be a GP. I would want to know who my patients with Covid-19 were. I would call them and ask them how they were. Unfortunately, that doesn’t happen. The GP may or may not be aware of the patient.”

The Office for National Statistics has recently begun to include deaths from Covid-19 in the community, including care homes. They show the total was more than 20% higher than the figure for hospital deaths alone.