COVID – 19
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We are currently in the midst of an unprecedented pandemic. A pandemic is when an epidemic has spread to a large number of countries and in this case the entire world. An epidemic is defined as a sudden significant increase in the number of cases of a ‘new’ illness contained within a community or country. The WHO declared Covid-19 a pandemic on 11th March 2020, following the rapid spread of the Coronavirus across the world. This has now hit the shores of the UK and placed the NHS on a ‘war footing’. 

COVID-19 SERVICE at Rejuvence Medical

At Rejuvence Medical we provide affordable private healthcare that doesn’t compromise on quality. We are transparent and always offer advice and treatments in the best interests of our patients. 

At Rejuvence Medical we are able to now offer the finger prick antibody test for Covid-19. We use a MHRA approved test kit, manufactured in the UK. Alongside this we provide a consultation service to help tell you whether you may have been exposed to Covid-19 and ramifications of this for yourself and your family.

The Point-Of-Care Antibody Finger Prick Test is NOT a COVID-19 diagnostic test. It is a screening test.

Our Doctors

Our team at Rejuvence Medical comprises 6 doctors who are actively working on the front line in primary care and Accident & Emergency, treating patients with Covid-19. They have great experience with the variety of symptoms and patterns of presentation of the Coronavirus. 

How can we help you?

At Rejuvence Medical, as part of the Covid 19 Service, we can help answer the following questions for you:

  1. I have been unwell – Could I have Covid 19?
  2. I have recovered – Have I had Covid 19?
  3. I have never had symptoms – Could I have had Covid-19 and not known about it?
  4. Am I at risk of infecting my household with Covid 19?

Please note that despite the test being designated an antibody test we are unable to tell you if you have immunity to Covid-19. Unfortunately it is still not clear whether exposure to Covid-19 and the presence of IgG antibodies renders someone immune to further infections. There have been reported cases of re-infection around the world. Hence if you have had Covid-19 this does not mean you can let your guard down.

What tests are available for Covid-19?

It is important to understand that all medical tests need to be interpreted together with your clinical symptoms. In the case of Covid-19, the timing of your symptoms is essential. The current gold standard, recommended by the WHO and Public Health England is in fact a viral swab. This involves using a special cotton wool bud being inserted right to the back of the mouth and nose. This test is not perfect and it needs to be done within the first 3 to 5 days of symptoms. To be sure it will pick up the virus it really needs to make you gag and shed tears. Hence this viral swab for Covid-19 is very difficult to perform. As a result there have been many reported false negative results, even in patients in ITU who clearly have signs of Covid-19 on their chest x-ray and CT scan. Viral swabs take on average 12-24 hours to process and there is a national shortage of testing laboratories. 

Viral Swabs are NOT appropriate for HOME TESTING

Many private clinics are offering viral swab packs to be used by individuals at home. At Rejuvence Medical we consider this inappropriate. It is very possible to get a false negative result providing false reassurance. It is a difficult test for health professionals to perform on their patients, let alone doing it on yourself.

Antibody finger prick test

The finger prick antibody test uses blood from a finger prick lancet similar to a blood sugar test. When deposited on the testing strip it is left for 10 minutes. The antibody finger prick test detects the presence of IgM and IgG antibodies. These antibodies appear as a line on the testing strip similar to a pregnancy test.

 

IgM antibodies are produced within 6 to 8 days of symptoms and are the first line of antibody defence against any infection. IgG antibodies are produced thereafter and remain. IgG antibodies stay forever and should provide immunity against future infection with the same pathogen.

The Covid-19 antibody finger prick test can provide three results that must be interpreted together with your clinical symptoms:

  1. POSITIVE – Both IgM and IgG antibodies detected: likely recent infection with immunity (OR possible re-infection)
  2. POSITIVE – Only IgG present: likely resolved infection with immunity
  3. POSITIVE – Only IgM present: active infection; no immunity developed as yet
  4. NEGATIVE – No IgG. No IgM: likely no exposure to Covid-19 (OR early active infection with insufficient levels of IgM for detection OR resolved infection with levels of IgG below detection threshold of testing strip)

It is clear from the possible testing strip results that it is absolutely essential they are interpreted together with your symptoms. The antibody finger prick test on it’s own cannot be used to diagnose Covid-19.

Do I have to come to the clinic to have the finger prick test?

Despite what has been published in the media, the Covid-19 antibody finger prick test is NOT a home test. It has to be performed in a healthcare setting by a healthcare professional. It is essential that the results of this test are then interpreted in the context of your symptoms (or lack of) as well as your personal circumstances including contact with household members. You will need to come to Rejuvence Medical to have this test carried out.

Our Covid-19 Medical Service

As part of the Rejuvence Medical Covid-19 Service you will receive:

  • Pre-test Covid-19 questionnaire to help us understand your symptoms and where you are in the disease timeline.
  • In clinic: Breathing assessment
  • In clinic: MHRA approved Covid-19 Finger Prick Antibody Test to help us confirm: 
    • Whether you are actively suffering with Covid-19 (please do NOT come to clinic if you have active symptoms)
    • Whether you have been previously exposed to Covid-19 and have IgG antibodies
    • Whether you have not been infected with Covid-19
  • Post-test report giving advice on the management of your symptoms and for how long you should self-isolate.
  • Advice regarding symptoms you should look out for and when you may need to consider going to hospital
  • Advice regarding contact tracing and concerns you may have for other household and family members. 

In addition we can also arrange for:

At Rejuvence Medical we are committed to providing the best possible care. All our doctors are actively working on the front line. We have a good understanding of the disease and appreciate the distress the nation is currently feeling. We aim to provide an affordable and competitive service in the best interests of all our patients

Covid-19 Booking-01
BACKGROUND
What is Coronavirus?

The Coronavirus is actually a family of RNA viruses. There are 4 widely distributed coronaviruses that are predominantly responsible for what we consider to be the ‘common cold’. The current Coronavirus outbreak is actually a new form of the virus that we have not been exposed to before. Collectively we have no immunity to this new viral strain.

What is COVID-19?

Following its discovery in China in late December this new strain of Coronavirus has been studied and has been found to be closely related to 2 other well known Coronaviruses. It is most closely related to the SARS (Severe Adult Respiratory Syndrome) virus. This specific virus is medically known as SARS-CoV1. It has also been found to be closely related to the MERS (Middle East Respiratory Syndrome) virus. This new Coronavirus has been named SARS-CoV2. The medical condition caused by getting infected with this new coronavirus is called COVID-19.

SARS-CoV2 epidemic started in late December 2019 in Wuhan, China. Initial epidemiological evidence suggests that most of the initial cases of Covid-19 occurred in patients who had all visited a local seafood market in Wuhan – Huanan Seafood Market. This market was subsequently closed on 1st January 2020.

Coronavirus is naturally hosted by bats. The specific route of transmission to humans is still unknown but it has been suggested that pangolins may have provided this route of transmission. Pangolins are a long snouted ant eating mammal. Despite being a protected animal, pangolins are sold illegally for their meat and their scales. Their scales are used in Chinese herbal medicines used for treating arthritis and skin conditions. It is illegal to trade in pangolins in China. However, the seafood market in Wuhan, thought to be the source of the outbreak, has been known to be associated with the illegal trade of pangolins. Scientists in China have compared the genetic code of the Coronavirus in pangolins with the current novel Coronavirus outbreak and found more than 99% similarity.

The last major Coronavirus epidemic was in 2003. This was the SARS epidemic and affected almost 26 countries with significant infection rates in China, Hong Kong, Singapore and Taiwan. It was not, however, declared a pandemic by the WHO and subsequently relatively well controlled. Again, it has been suggested that the original animal reservoir for SARS was from bats. A mutation resulted in the virus spreading to Civet cats and the first infected humans were identified in Guangdong in China. The SARS epidemic consisted of almost 8000 cases with transmission occurring from person to person. SARS infection consists of a flu-like illness with fever, malaise, headache, diarrheoa, cough and ultimately severe respiratory distress.

Both SARS and Covid-19 are Coronaviruses and result in similar symptoms. SARS has a higher death rate than Covid-19. However, Covid-19 is more contagious and hence able to spread much faster and to more people than SARS. This is the main reason the Covid-19 epidemic has escalated to a pandemic and affected more than a million people worldwide.

TRANSMISSION

As already mentioned, the main reason the Covid-19 outbreak has escalated to a pandemic is because it is extremely contagious. Transmission of Covid-19 is by ‘large droplet transmission’. This is similar to flu and the risk of transmission is limited to 6ft or 2m from the patient. Transmission is in 2 forms. 

Contact transmission occurs when an infected patient coughs and emits large droplets that land on a surface. Depending upon the type of surface the virus can survive for up to 4 days. Studies have shown that SARS-Cov2 can survive on plastics and metal surfaces for up to 72hours (average 5-8 hours). It can also survive for long periods of time on clothing and cardboard. When someone else touches these surfaces and subsequently touches their face, specifically nose, mouth and eyes they can get infected. Hence the importance of regular cleaning of hands and surfaces as well as avoiding touching the face.

The second, and still controversial, mode of transmission is airborne. Some studies have suggested small viral particles can remain aloft in the air for many hours and hence the need to wear a face mask in and around infected individuals. On average a person suffering with Covid-19 will spread the virus to 3 other people. In densely populated gatherings this can increase to 15. This is the reason governments around the world have introduced social distancing and lockdowns in an attempt to slow down the spread of the virus.

Infected individuals are most likely to spread the virus in the first 8 days of the illness. However, it is important to realise that not everyone will develop symptoms. Hence even asymptomatic transmission is possible.

SYMPTOMS

The SARS-CoV2 Coronavirus specifically binds to a specific cell receptor found predominantly in the lungs but also in the lining of the gut. This receptor is known as the Angiotensin Converting Enzyme 2 receptor. The virus causes damage in 2 specific ways. Firstly there can be direct viral damage to the cells of the lungs resulting in difficulties in breathing.

Secondly, in a small subset of sufferers, once the virus has been cleared by the body there can be a hyper-inflammatory reaction resulting in further damage to already damaged cells in the lungs and gut causing further respiratory problems. The net result is a condition known as Adult Respiratory Distress Syndrome. This causes severe difficulty in breathing that requires supplemental oxygen and even intubation and ventilation (assisted breathing). Once it gets to this stage, depending on whether the sufferer has other underlying conditions, as well as the extent of the damage to the lungs, some patients do not recover.

It is important to stress that only a very small proportion of people contracting Covid-19 will need help with their breathing. The vast majority will recover with no assistance needed.

Covid 19 results in symptoms that are initially quite similar to the flu that we are all familiar with. Fever occurs in only half of patients when they first attend hospital. The absence of a fever does not exclude the possibility of having Covid 19. The majority of sufferers will have lower respiratory tract symptoms – specifically a persistent dry cough. Around 10% of patients can have gastrointestinal symptoms (GI) including diarrheoa and nausea. These GI symptoms often appear before developing a fever or shortness of breath.

Although the vast majority of patients will recover well, a small proportion can develop quite significant shortness of breath. This is especially more likely in the elderly, those with underlying health conditions such as high blood pressure, heart disease and diabetes, those with long standing respiratory conditions such as asthma or COPD and those taking immunosuppressant medications such medicines for cancer and steroids. What has become particularly apparent is that the extent of the shortness of breath can be quite misleading. Often at rest many cope quite well but on exertion such as walking or going up the stairs oxygen levels can drop to dangerously low levels.

A small proportion (2%) of patients present with a sore throat include pharyngitis and even enlarged tonsils.

The incubation period of an infection is the time taken for symptoms to first appear following initial exposure. In the case of Covid 19 this is typically 4 days but can be anywhere from 2 days up to 14 days. This is why anyone living in a household where others are unwell should self-isolate for at least 14 days. For those who deteriorate shortness of breath can become apparent at around 6 days after first symptoms appear and often these patients require hospital admission at day 8. Should there be further deterioration, patients often require intensive care input at day 10. However, the vast majority should recover within 7 days of becoming symptomatic.

INVESTIGATIONS

Covid 19 is a brand new disease. We are learning all the time thanks to the experiences shared by doctors and patients from countries where the outbreak started, notably China and more recently Italy.

There is no specific blood test that can be carried out to confirm the presence of SARS-CoV2. However, should anyone become unwell and present to hospital there are blood tests that can point in the direction of Covid 19.

Most commonly a Full Blood Count (FBC) and C-Reactive Protein (CRP) are performed. The FBC can show a normal White Cell Count (Infective marker) with normal neutrophil levels (markers of bacterial infection). Interestingly the lymphocyte count is very often found to be quite low – lymphopenia. There is also often evidence of mildly reduced platelet count (thrombocytopenia). In addition the CRP is raised and has proved to have a very good association with disease severity and when very high is suggestive of a poor outcome with the likely need for intensive care support.

An arterial blood gas is very helpful in the evaluation of the need for supplemental oxygen in patients with Covid 19. This is where a sample of blood is often taken from the radial artery and run through a machine to measure the oxygen carrying capacity of the blood. The lower this is the more poorly the patient is and can help doctors decide whether intensive care support is required. This is only performed in those patients who are relatively short of breath and have evidence of poor oxygen saturations on hospital monitors.

Those patients who develop more severe symptoms have been found to have evidence of changes on their chest x-ray especially when this is performed around day 8 of the illness. Chest x-rays often show evidence of increased fluid in the lungs alongside changes that can be representative of varying degrees of Acute Respiratory Distress Syndrome (ARDS). The more severe the changes the more short of breath the patient is. There can also be evidence of pneumonia. In more severe disease, there are characteristic changes on CT scans of the chest, although this is not common practice for the purposes of diagnosis.

TREATMENT
What treatments are available for Covid 19?

No specific treatment for Covid 19 has been officially approved by any major health organisation in the world. No vaccine is available as of yet and this is of little help to those who are already infected. Covid 19 is a viral illness and hence antibiotics will not help in the first instance. Treatment available at the moment is mostly symptomatic. This means only measures to help with symptoms are available such as regular paracetamol and hot drinks. 

It is important to remember that the vast majority of sufferers will have only mild symptoms very similar to the ‘common cold’. However, as mentioned previously, a small subset of infected persons will suffer more severe symptoms. Although not absolute, those most at risk of getting more severe symptoms normally have pre-existing medical problems and/or the elderly. However, over the last 3 weeks I have seen more than a few young, previously healthy individuals, really suffer badly with shortness of breath and respiratory symptoms that have needed hospital admission.

Both chloroquine and hydroxychloroquine are medications that are typically used to treat malaria. They are also used for the treatment of Lupus and Rheumatoid Arthritis. Chloroquine and hydroxychloroquine are known to have some indirect antiviral and antiinflammatory activity. There is also evidence to show that this medication has an effect on the Angiotensin Converting Enzyme 2 receptors – the same receptors that the Covid-19 virus (SARS-CoV2) affects.

Published animal studies from China and human trials in France have demonstrated potential benefits from chloroquine and more so from hydroxychloroquine in the treatment of Covid 19. Researchers in France found reduced viral load in patients treated with hydroxychloroquine. Although relatively safe, there are complications associated with the use of these drugs including complex cardiac rhythm disturbances. In addition dosing regimens are still not clear. As a result the National Institute of Clinical Excellence (NICE) has not endorsed chloroquine and hydroxychloroquine as treatment options for Covid-19. However, there are trials underway in the UK

In theory antiretroviral drugs, commonly used for the treatment of HIV, should provide some benefit against Covid-19. However, there are very few published trials and only anecdotal evidence to support their use at present. Some have suggested that this may be due to these medications being administered too late in the disease course and that patients who have received treatment were already too unwell. This is supported by similar evidence in the SARS epidemic where it was felt that perhaps antiviral medication would have been more effective if given in the first few days of the infection. This is very clear when it comes to the treatment of influenza (common flu) whereby Tamiflu is given to those at risk of severe disease within 24 hours of the onset of symptoms. Little benefit is achieved with Tamiflu if started after this.

Recently there has been increased interest in the use of high dose intravenous (IV i.e. via a drip) Vitamin C for patients admitted to ITU with severe sepsis and/or acute respiratory distress syndrome (ARDS). The controversial CITRIS-ALI trial suggested improved outcomes in ITU patients with ARDS, who were given high doses of IV Vitamin C. There may be some benefit from IV Vitamin C in Covid-19 but data is scarce. High dose IV Vitamin C is extremely safe and commonly administered in the private sector at various clinics around the country. High dose IV Vitamin C has been shown to successfully increase the levels of Vitamin C circulating in the bloodstream whereas the same effect cannot be achieved with oral Vitamin C supplements.

Hospital admission for treatment of Covid-19 is warranted when infected patients have breathing difficulties severe enough to warrant supplemental oxygen. As has been mentioned repeatedly, the vast majority of sufferers will only get mild symptoms and in fact many may not get any symptoms at all. For those who do go on to develop severe symptoms the main problem is hypoxaemia – not getting enough oxygen into the bloodstream. This is the result of significant damage to the lungs either directly due to viral damage and/or the result of a severe inflammatory reaction. The result of all of this is the inability of the lungs to extract oxygen and in some cases secondary infection such as pneumonia (Covid pneumonia).

The main objective of any hospital admission is to help patients with their breathing for as long as it takes them to fight off the virus on their own. The breathing assistance they may receive can be in the form of simple oxygen therapy, high flow nasal oxygen therapy (Optiflow), Continuous Positive Airways Pressure (CPAP) support and in the worst cases, intubation and ventilation (i.e. induced coma whilst they are put onto a ventilator to breathe for them). In certain specialist units ExtraCorporeal Membrane Oxygenation (ECMO) may be available. This is in principal, similar to dialysis for patients with kidney failure. Oxygen is infused into the blood and carbon dioxide removed providing the heart and lungs with some respite.

COVID-19 TESTING
How can we test for Covid 19?

The effectiveness of diagnostic testing for Covid 19 has been fundamental in the fight against the current pandemic. Testing for Covid 19 has proven to be quite controversial and has limited our ability so far to control the spread of the virus. Those countries able to offer faster and more widespread testing have tended to fare better than those unable to do so. 

The current gold standard for testing is a viral swab. More recently there has been increased testing of fluid obtained from the lungs using tracheal aspiration or a technique called broncho-alveolar lavage. This type of testing is restricted to patients in intensive care who are intubated and ventilated. Great hope has been pinned on rapid finger prick point of care testing that is able to measure antibody levels in the blood to indicate whether someone has an active Covid 19 infection, has immunity to Covid 19 and hence has already had and recovered from covid 19 or indeed has not had the illness at all yet.

Swabbing has been the gold standard test carried out in hospitals to confirm a diagnosis of Covid 19. This involves inserting a cotton wool bud into the nose and mouth to take samples right from the back of the throat and deep in the nostrils. This is where the SARS-CoV2 virus typically stays. These swabs are then analysed using a technique called Polymerase Chain Reaction (rt PCR). This is a very specialised test that can only be carried out in a handful of accredited laboratories and often can take upto 24 hours to process. With the increased spread of the coronavirus governments round the world have invested heavily in testing facilities and the speed of testing has improved but is still limited to 12 to 15 hours turn around time in the UK.

Although considered to be the gold standard there are still problems with relying on swabs for diagnosing Covid 19. First of all the swab is not always particularly accurate with many documented cases of ‘false negatives’. This is because there are a number of factors that can negatively affect the outcome of the test. 

Firstly the swab needs to be carried out by a health professional who has experience in doing these swabs well. It is not enough to just rub the cotton wool bud against the roof of the mouth and inside the nose. Often the swabs need to be inserted quite deep to the extent that the patient is made to gag and shed tears. 

Secondly there needs to be enough of the virus in the mouth and nose to be able to pick up sufficient amounts on the swab to be detected by PCR. Hence, often when carried out very early in the illness they can come back negative when in fact the patient has Covid 19 but the viral load is not high enough. Indeed there have been documented cases of false negative results even in patients who are intubated in ITU and are clearly still actively infected. In China, prior to discharging patients from hospital, two or more negative swabs would be required within 24 hours of each other. 

Finally the third major problem with viral swabs is the time taken for the results to be obtained by PCR and the capacity to carry out tests. In the midst of a pandemic it is essential to be able to test for the disease as quickly as possible and on a massive scale.

In response to the Coronavirus outbreak in Wuhan, a number of Chinese biotech companies were the first to develop a rapide 15 minute finger prick test to detect the presence of antibodies specific to the SARS-CoV2 virus. These work along the same principles as a pregnancy test using a technology known as lateral flow. A small amount of blood is taken from a finger prick and placed on a strip test. A solution is then added to this and the strip left to sit for 15 minutes. There are three lines that can potentially appear. The first line to appear is the control line and confirms that the strip has worked and that blood has travelled all the way along the strip. The remaining two lines refer to the presence of two types of antibodies – IgM and IgG.

In response to a new infection the body will initially produce IgM antibodies within 3 to 6 days of infection. These antibodies help to fight the virus in the first instance and their levels are high during active infection. Towards the end of the illness the body starts to produce IgG antibodies and the levels of these antibodies soon increase as IgM levels reduce, typically after 8 days. IgG antibodies form part of the memory function of our immune system. Should one be exposed to the same virus again in the future IgG antibody levels increase much faster and quickly neutralise the virus before illness can set in. 

The rapid point of care tests that have been developed are designed to specifically detect the presence of IgM and IgG antibodies that are specific to the SARS-CoV2 virus. If IgM antibodies are detected in the blood sample the line corresponding to IgM will appear and suggest active infection. Should IgG antibodies be detected then the corresponding IgG line will appear and suggest the presence of immunity against the virus and likely much earlier exposure. It is possible to have only IgM antibodies (suggesting early active infection), only IgM antibodies (suggesting infection that has resolved with established immunity) or indeed both (suggesting active infection with development of new immunity). The lack of both lines would suggest the patient has not been previously exposed to SARS-Cov2 and has no immunity against it.

Over the past month there has been a lot of talk in the media about the possibility of rolling out a home testing kit. Boots and Amazon have made it well known that they are involved in the logistical planning of this potential approach. There is NO home testing kit available at present.

It has been suggested by many journalists that the antibody finger prick test can be used as a home testing kit. This is NOT correct. The antibody home testing kit cannot be used at home. The MHRA have approved a handful of finger prick tests. They have specifically stated that the approved tests are approved ONLY for use by a healthcare practitioner within a healthcare setting. They cannot be used by patients on their own at home. This makes sense as it is essential that any testing for Covid 19 goes hand in hand with a clinical consultation of somesort. Therefore we would advise that no one should purchase any Covid 19 testing kits for ‘home use’.

The first antibody point of care tests were developed in China and trialled in 6 different provinces at 8 different clinical sites. A total of 525 patients were tested using viral swabs and the antibody finger prick test. The results of the finger prick test were compared to the viral swab results. In total, based on viral swab results, 397 positive results were identified and 128 negative. The finger prick antibody test identified 352 positive patients. 

In order to understand how accurate the test is researchers calculate the specificity and sensitivity levels of a diagnostic test. Specificity is defined as the proportion (%) of patients with a negative result who actually DON’T have the disease. Hence a poor specificity would mean the test is producing a lot of false negative results. The sensitivity is defined as the proportion of patients with a positive test result who actually DO have the disease. Hence a poor sensitivity would mean the test is producing a lot of false positive results. 

In the case of the antibody tests evaluated in this study the specificity 90.63% and the sensitivity was 88.66%. The ideal test would have a sensitivity and specificity of 100%. The researchers believed the antibody finger prick test was suitable for mass testing but only in conjunction with a full clinical assessment. The main advantage of such rapid testing would be to be able to get an idea of how many people are likely to be immune to Covid 19 and recovered fully.

The main advantage of the finger prick antibody test is that it can be carried out at the bedside and can deliver a result in 10 – 15minutes. This is in sharp contrast to the viral swabs that require up to 2-3 days and need to be sent to a specialised central lab. It is also much cheaper and requires little training. For the purposes of mass testing to evaluate a public health strategy at government level it is potentially a great tool to use.

Since the original development of this antibody test many other companies have developed their own version. At present there are more than 60 different companies worldwide developing the finger prick antibody test. Of these, many have been given CE approval. CE marking is a certification mark that indicates conformity with health, safety, and environmental protection standards for products sold within the European Economic Area (EEA). However, for the purposes of gaining this CE mark the EU asks for the relevant companies to provide their own data and does not test the product themselves. In the UK, in addition to the CE mark, any such device requires MHRA approval as well. In fact it is illegal to use any non-MHRA approved devices of this sort. The MHRA have to date approved 3 devices and the FDA (USA) only approved one. The government is carrying out studies to confirm the reliability of these tests.

Since the start of the outbreak there have been a number of well publicised clinics on Harley Street and in other parts of the country that have been providing Covid 19 testing. They have been specifically criticised and accused of profiteering at a time of hardship in the country. It is important to understand that the vast majority of these clinics have been providing at home viral swab kits that are then sent to a laboratory with prices up to 375.00.

In our opinion this practice is not correct for a number of reasons. Firstly the main problem with viral swabbing is that it’s accuracy is extremely dependent upon technique. There have been multiple documented cases worldwide and in NHS hospitals where unwell patients in hospital have clear evidence of Covid 19 in terms of their symptoms, chest x-ray and CT scan findings and yet their swabs have been negative. This demonstrates how difficult it is to perform the swabs correctly. As per Public Health England, the swabs need to go right to the back of the throat ensuring the patient gags and up one nostril until they start to shed tears. This is clearly not something that can be done on your own at home. This is likely to have led to a lot of false negatives, false reassurance and in the worst case scenario increased spread with people believing they have not been exposed or infected.

Secondly when the swabs are performed in hospital there are strict protocols in place to ensure the swabs are bagged appropriately such that there is no transfer of virus to the couriers when they are moving them to the lab. With the at home kits there will not be the same level of care and bags and envelopes in which the swabs are posted back to the central lab are more than likely to be contaminated with Covid 19 putting the postal service at risk. There have been studies that have documented risk of transmission of disease through the post as a very real risk and hence this associated practice with the home testing swabs is also unacceptable.

Finally, the home swabbing service is often not associated with any proper clinical consultation. Therefore there is no clinical context to the swab results alongside appropriate advice on how long to self isolate for and what steps should be taken. Any testing for Covid 19 is incomplete without a full and proper consultation with a healthcare provider.

Our advice is therefore not to go for home swabbing kits.

Since the outbreak of Covid 19 in the UK there have been a few changes to guidelines regarding Covid 19 testing by the NHS. As of the beginning of April the following practices are in place. All patients being admitted to hospital, irrespective of their pattern of presentation, are being swabbed and tested for Covid 19. Patients who are being discharged home with no follow-up arranged, are NOT being swabbed. They are being given advice that they may have Covid 19 and hence should follow appropriate advice. Those with follow-up arranged, may be swabbed, and the results discussed with them the following day via telephone/video consult with community healthcare practitioners.

The general public cannot ask for a test on the NHS unless they fulfil the above criteria. Staff testing arrangements have been put in place and vary from trust to trust. Local policy is dictating the arrangements that have been established for staff testing.

The government has aspirational plans in place to ramp up testing. The government recognises that the cornerstone of tackling the outbreak as quickly as possible and any plans to lift the lockdown are completely dependent upon being able to understand the spread of the disease, how many people have been infected and most importantly how many are likely to have some degree of immunity. This would be in line with the ‘herd immunity’ approach. There are plans for ‘drive through’ swabbing but these remain to be set up and put in place. At present there are no firm plans in place for mass testing using finger prick antibody testing.

PUBLIC HEALTH ENGLAND RESPONSE
What is the UK government doing about the Coronavirus pandemic?

The UK government, in line with other countries around the world, has made a series of decisions in an attempt to reduce the impact of the coronavirus pandemic. In addition to bolstering up the NHS a nationwide lockdown was announced on 23rd March and has since been extended with no official end date in site. China was the first nation to carry out a lockdown approach that they initiated in Wuhan on 23rd January. This has only been lifted in the last few days. The purpose of the lockdown is to significantly slow the spread of the coronavirus. The reason behind this is to ‘flatten the curve’.

What is social distancing?

Covid 19 is extremely contagious with a transmission rate of 2.68. This means every person infected with Covid 19 is likely to spread it to 2.68 other people if there are no social distancing measures put in place. Hence within 30 days a single person can spread the disease to 406 people. However, by reducing exposure through social distancing (stopping people from and lock down measures it is possible to reduce the transmission rate to 0.625 and this would mean a single infected person would spread the disease to only 2.5 people in a 30 day period. Social distancing is a non-pharmaceutical measure used to reduce the rate of spread of a contagious infection by enforcing a physical distance between people and preventing close contact.

What do they mean by ‘flatten the curve’?

The spread of Covid 19 is expected to follow a curve that includes a massive acceleration phase. In the UK, as in all countries, if no measures to reduce exposure and transmission are put in place, the NHS would be overrun with patients with extremely severe symptoms. If this is allowed to happen many many more deaths would occur as there would not be enough health care provisions to treat even those expected to recover. By reducing the exposure and transmission rates through social distancing and the lock down, the acceleration phase of this curve is ‘flattened’ and hence the number of patients needing hospital admission at any one time would be significantly reduced allowing the NHS to be able to cope and provide the best care possible to as many people as possible resulting in much fewer deaths. However, this approach does mean that the pandemic is likely to last for longer and although there are much fewer deaths, overall the infection rate is likely to only be partially reduced.

Covid-19 has very limited treatment options. There is no recognised medication to help treat Covid-19. There is no vaccine available yet. For the few people who do develop severe symptoms all that can be offered at the moment is support with breathing. 

For those with the most severe symptoms this means putting them onto a ventilator. The issue with this is that there is a significant shortage of ventilators in the UK. In addition not everyone who is put onto a ventilator can easily be weaned off it. In view of the high rate of spread of Covid-19 and the potentially large numbers of people that may need ventilator support relative to the number of ventilators available the government and Public Health England have had to enforce a nationwide lockdown and social distancing. 

Despite these measures, on the front line, there is still a significant strain on scarce resources. The NHS is not equipped to deal with the large number of affected patients. The government and the NHS have worked tirelessly to increase ventilator capacity. Every hospital in the country has reconfigured their hospital setup to successfully more than double their ITU capacity. However, even this will still not be enough to cope with demand. As a result doctors are having to make very difficult decisions about who to treat and who to withdraw treatment from.

There is a huge body of published evidence to show what types of patients do well on a ventilator and who don’t. The elderly and those with significant underlying health conditions do not fare well on a ventilator. Those with significant respiratory problems such as COPD often cannot be taken off a ventilator once they have been put on it. Using guidance issued by the National Institute of Clinical Excellence (NICE), doctors are having to make decisions regarding which patients are likely to recover and who are not in order that the precious number of ventilators available are being given to those with the greatest chance of survival. We are NOT at the point of rationing but difficult conversations are having to be made with the families of those who are extremely unwell with Covid-19.

In response to this unprecedented demand the government has announced the establishment of a series of temporary hospitals up and down the country. The Nightingale project comprises a series of units (the largest being a 4000 bed unit at the Excel, Docklands, East London) that will serve as an overflow for hospitals struggling to cope with demand. Patients will be transferred from hospitals to these units in order to make increased capacity for new admissions. Many of these units are already taking and treating patients.

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