Tag: Covid-19

Wastewater Surveillance for Covid-19

Wastewater surveillance is a technique that can be used to detect and track the spread of infectious diseases, including Covid-19. Wastewater is a rich source of genetic material from the people who use facilities in locations such as schools. By testing wastewater for the presence of viruses, public health officials can get an early warning of an outbreak before it becomes widespread.

Our recent study published in the journal PLOS One found that wastewater surveillance can be used to detect Covid-19 with high accuracy. The study, which was conducted in England collected wastewater samples over a period of six months. We found that wastewater samples from areas with high rates of Covid-19 infection had significantly higher levels of SARS-CoV-2 genetic material than samples from areas with low rates of infection.

We also found that wastewater surveillance can be used to track the spread of new variants of SARS-CoV-2. We were able to identify the Alpha and Delta variants in wastewater samples before these variants were detected in clinical samples.

Wastewater surveillance is a valuable tool for public health officials who are working to prevent the spread of Covid-19. It is a cost-effective and efficient way to identify outbreaks early and take steps to mitigate them. In addition to detecting COVID-19, wastewater surveillance can also be used to detect other infectious diseases, such as influenza and norovirus. This makes it a valuable tool for public health surveillance and outbreak response.

Wastewater surveillance will become increasingly important for protecting public health. It is a valuable tool that can be used to identify outbreaks early, track the spread of new variants, and monitor the effectiveness of public health interventions.

The covid-19 pandemic three years on

In a recent article in the British Medical Journal, I discuss where we are three years after the start of the Covid-19 pandemic in the UK and what broad comments can we make about the UK’s ongoing response to the pandemic.

The UK is certainly in a better place now than it was in the first year of the pandemic; a period when many people became seriously unwell, resulting in significant pressures on the NHS and a very large number of deaths. One positive step is the creation of the UK Health Security Agency. This begins to address the weaknesses that arose in England’s health protection functions following the abolition of the Health Protection Agency in 2013 and is recognition that the UK needed a government organisation that was focused on health protection. However, the devolved nature of the UK means that some responsibilities for health protection lie with the UK government, while others lie with the national assemblies in Wales, Scotland, and Northern Ireland. This does create scope for a fragmented response to the still-ongoing covid-19 pandemic (and future outbreaks of other infectious diseases); as well as the possibility of political tensions between the UK governments and the national assemblies in the devolved nations as we saw at times during the previous three years.

The UK government now views the worst of the pandemic as being over. The UK was among the first countries to start a vaccination programme against covid-19. Vaccination combined with immunity from prior infection has reduced the severity of illness from covid-19 in the UK with deaths and hospital admissions both now at a much lower level than they were in January 2021. The UK is now highly reliant on vaccination to suppress the impact of covid-19 on our society and its impact on the NHS. Maintaining this protection will probably require regular booster vaccinations for the most vulnerable groups in society, such as the elderly, the immunocompromised, and those with significant long term medical problems. Conversely, routine covid-19 vaccination for people under 50 years of age is likely to stop other than for those who are in a high clinical risk group or who are carers.

Take-up of the first two doses of covid-19 vaccination was very high thanks to the positive attitude to vaccination in the UK population and the rapid mobilisation by the NHS of sites for delivering vaccines. However, the most recent booster campaign carried out in the autumn and winter of 2022-23 saw a much lower uptake of vaccination. Addressing vaccine hesitancy, tackling disinformation, and improving confidence in vaccines will remain key aims for the NHS, health professionals and public health agencies in the UK. The risk of a further wave of serious illness from covid-19 remains, either from declining population immunity or from the emergence of a new variant of SARS-CoV-2 that can bypass pre-existing immunity and cause more serious illness than currently circulating variants. Regular vaccination of the most vulnerable groups will help mitigate these risks, as will covid-19 treatments for the groups at highest of serious illness.

One area that the UK excelled during the pandemic was in the use of data to monitor the epidemiology of covid-19 and the effectiveness of vaccines. The UK also set up a range of research studies that informed the pandemic response not just in the UK, but globally as well. However, much of this data collection and analysis infrastructure is now being dismantled. This will make the UK much more reliant on conventional methods of measuring the impact of a disease as opposed to using data from the new systems—such as the coronavirus (COVID-19) Infection Survey—established over the last three years. It is essential the information systems we have in place continue to provide the data needed to monitor covid-19 trends and rapidly identify any resurgence in covid-19.

The UK has spent considerable sums on managing the pandemic and mitigating its impact on the NHS and the economy. As we move forward into the next phase of pandemic, interventions to manage covid-19 will need to be evaluated through the usual routes used by the NHS; with slower adoption of interventions than we saw earlier in the pandemic—as shown, for example, by NICE refusing to endorse the use of Evusheld. Future pandemic planning will also need to consider the impact of interventions on children. Much of the focus earlier in the pandemic was on protecting older people. But the pandemic also had important impacts on the physical and mental health of children as well as on their educational and social development in the UK and elsewhere. The management of people with post covid-19 syndromes (long covid) also remains challenging with demand far outstripping the supply of services for diagnosis and management.

The NHS in the UK faces many challenges and investment in interventions for managing covid-19 will need to be compared to interventions for managing other health priorities—such as urgent care, general practice, mental health and cancer—to ensure that maximum population benefit is obtained. For example, vaccine booster programmes for covid-19 will need to examine the incremental cost-effectiveness of vaccination in different population groups to identify priority groups for vaccination rather than vaccination being made available to all adults. The era of issuing “blank cheques” for tackling covid-19 is now over and investment for interventions for covid-19 will need to compete with investment in other public health and healthcare services.

Impact of vaccination on Covid-19 hospital admissions in England

Our new article in the Journal of the Royal Society of Medicine examines the impact of vaccination on hospital admissions for Covid-19 in England during 2021. Covid-19 vaccination substantially reduced the risk of hospital admission, particularly in people who received three doses.  We used data over a whole calendar year covering multiple variants of SARS-CoV-2, variable case rates and changing vaccine uptake.

This provides a population-level overview of the impact of vaccination that is not possible from studies over a shorter period. Using primary diagnosis of Covid-19 as the inclusion criteria increases the specificity of our study by excluding those co-incidentally Covid-19 positive but admitted for another reason. We excluded “ghost patients” that can bias the estimates of vaccine effectiveness.

We report a dose-dependent effect of vaccination, as well as waning of the effectiveness of each vaccination dose, highlighting the value of booster vaccinations. Our analysis supports an ongoing programme of booster vaccinations, especially in the elderly and risk groups.

Factors influencing COVID-19 vaccine hesitancy among South Asians

Our new study in JRSM Open led by Dr Raj Chandok and Dr Poonam Madar examines factors influencing Covid-19 vaccine hesitancy among South Asians in London. Vaccines have a key role in suppressing serious illnesses, hospitalisations and deaths from Covid-19. London has amongst the lowest Covid-19 vaccination rates in the UK and it’s important to understand the factors behind this so we can work better with local communities to address this key public health challenge. This includes looking at factors such as confidence in Covid-19 vaccines, complacency about the severity of illness arising from Covid-19, communication about vaccines in both the mainstream media and social media, and the context in which people live and work.

Implementation of covid-19 vaccination in the United Kingdom

Our new paper in the British Medical Journal reviews the implementation of the UK’s Covid-19 vaccination programme. The programme is essential in keeping down the number of serious cases, hospitalisations and deaths from Covid-19 and allowing society to function more normally. Overall the programme performed well. But it’s important to address some common misconceptions about the programme. Firstly, the rapid implementation of the Covid-19 in vaccination in the UK was not due to Brexit. When the programme started, the UK had not finalised Brexit. Secondly, the vaccination programme was good and all those who supported the programme are to be congratulated for their efforts but it was not “world-leading” as some politicians have claimed. Many other countries have outperformed the UK in areas such as vaccine uptake.

One limitation of current vaccines is that although they are very successful in reducing the number of serious cases of covid-19, they are less effective in preventing infection from SARS-CoV-2, which means that vaccinated people can still become infected and infect others. Early in the vaccination programme, this was often not communicated well to the public, leading to unrealistic expectations about how well vaccines would suppress the risk of infection, particularly with the emergence of new variants that reduced vaccine efficacy.

The UK became the first country in Europe to grant emergency use authorisation for a covid-19 vaccine when the MHRA gave approval for use of the Pfizer-BioNTech vaccine in adults on 2 December 2020. This decision took place when the UK was still operating under EU law. Overall, the policy for prioritising people for vaccination was fair but was criticised for not including ethnic minority groups or key occupational groups other than health and care workers, such as people working in public transport or teaching. The pandemic had major effects on the education of children, for example, and it could be argued that staff working in schools should have been prioritised in the same way as NHS staff to reduce the disruption caused by the pandemic to children’s education.

Shortly after the start of the vaccination programme in the UK, the government decided to prioritise delivery of the first dose of vaccine over the second dose, based on advice from the JCVI. This meant a delay in giving the second dose of vaccine from 3-4 weeks after the first dose to 12 weeks. The immunisation programme was disrupted by this decision, with many people having their appointments for their second doses cancelled. A key question for the Covid-19 Inquiry is why the JCVI did not consider a delayed second dose policy before the programme started. The Inquiry also needs to look at what plans were in place for evaluating the effects of the delayed second dose on clinical outcomes such as infection, hospital admission and case fatality rates and on the delivery of the vaccine programme.

Although the UK was an early adopter of covid-19 vaccines for use in adults, it was slower than many other countries to implement vaccination for 16-17 year olds, then for 12-15 year olds, and finally for 5-11 year olds. This also needs careful review by the Covid-19 Inquiry. Additional problems arose after the decision to give some immunocompromised people a third primary dose of vaccine. The rationale was that immunocompromised people often had a poor response to two doses of vaccine and that a third dose would give improved protection. The third dose programme was rolled out with little central or local planning, resulting in considerable confusion among both the public and NHS staff and leading to delays in many eligible people getting their third primary vaccine dose. Key lessons from this component of the vaccination programme were the need to give the NHS adequate time to plan and to ensure that NHS staff are fully briefed in advance of any public announcement or media briefing about vaccination policy. It’s also essential to look at the method of vaccine delivery. In England, there is now a very fragmented system. In the longer term, we need to look to integrate Covid-19 vaccination with other vaccine programmes in primary care and schools.

One area in which the UK excelled internationally was using data from the NHS, covid-19 testing, and national mortality records to monitor vaccine uptake, safety, and effectiveness. Congratulation to PHE and then to the UKHSA who set up this work.

The UK is currently very reliant on overseas manufactured vaccines. We must plan consider how we ensure that the UK can develop, test, and manufacture vaccines for the current and any future pandemics at the speed and quantity needed.

The feedback on our article from patients emphasised the importance of clear, positive messages about vaccination for the public; and personalised support for people who were vaccine hesitant or who had concerns about vaccination to help increase vaccine uptake. Access to vaccination at a local site was also important, particularly for older people or those with limited mobility. Finally, there are many questions about vaccination that the UK’s Covid-19 Inquiry will need to consider. Some of these are summarised below.

Questions for the UK’s Covid-19 Inquiry

  1. What should we be doing to secure the legacy of the covid-19 vaccine research and delivery strategy for vaccine science, vaccine manufacturing, public health, and pandemic preparedness?
  2. Why hasn’t the UK established a pipeline for the rapid development of RNA vaccines?
  3. Why did the UK lag behind many other countries in recommending covid-19 vaccines for children?
  4. How would we respond to a future pandemic causing high levels of morbidity and mortality in children?
  5. Was sufficient attention paid to targeting groups who were likely to be vaccine hesitant?
  6. What can be done to build on the JCVI’s communications and operations—particularly around public and patient involvement and engagement and its position on equality, diversity, and inclusion?
  7. Why did the JCVI not recommend a delayed second dose strategy in its initial recommendations to the government in 2020? What impact did this have?
  8. What is the best method of covid-19 vaccine delivery in the future?
  9. Should staff working in schools also have been included in the initial occupational groups targeted for vaccination (such as health and care workers) reduce the effect of the pandemic on schools, given the many adverse effects of the pandemic on the education, social development, and the physical and mental health of children?
  10. Did the UK government take the correct decisions about vaccine procurement? Was the UK correct to work alone on procurement or should there have been greater collaboration with the EU?
  11. What impact did the over-procurement of vaccines by developed countries such as the UK have on vaccine equity and on the supply of vaccines for lower income countries early in the pandemic?

Patient outcomes following emergency admission to hospital for COVID-19 compared with influenza

Our recent study in the journal Thorax examined patient outcomes following emergency admission to hospital for COVID-19 compared with influenza. We used routinely collected primary and secondary care data. Outcomes, measured for 90 days follow-up after discharge were length of stay in hospital, mortality, emergency readmission and primary care activity.

The study included 5132 patients admitted to hospital as an emergency, with COVID-19 and influenza cohorts comprising 3799 and 1333 patients respectively. Patients in the COVID-19 cohort were more likely to stay in hospital longer than 10 days (OR 3.91, 95% CI 3.14 to 4.65); and more likely to die in hospital (OR 11.85, 95% CI 8.58 to 16.86) and within 90 days of discharge (OR 7.92, 95% CI 6.20 to 10.25). For those who survived, rates of emergency readmission within 90 days were comparable between COVID-19 and influenza cohorts (OR 1.07, 95% CI 0.89 to 1.29), while primary care activity was greater among the COVID-19 cohort (incidence rate ratio 1.30, 95% CI 1.23 to 1.37).

We concluded that patients admitted for COVID-19 were more likely to die, more likely to stay in hospital for over 10 days and interact more with primary care after discharge, than patients admitted for influenza. However, readmission rates were similar for both groups. These findings, while situated in the context of the first wave of COVID-19, with the associated pressures on the health system, can inform health service planning for subsequent waves of COVID-19, and show that patients with COVID-19 interact more with healthcare services as well as having poorer outcomes than those with influenza.

The findings relate to 2020, a period before Covid-19 vaccination began and when different variants of SARS-CoV-2 were circulating in the UK. We aim to update the analysis to see how Covid-19 outcomes have changed since that period compared to outcomes from influenza.

Covid-19 rates are increasing again in the UK – What does the public need to know?

Why are so many people coming down with Covid again?

The current wave of Covid-19 infections is being caused by highly infectious subvariants (BA.4 and BA.5) of the Omicron variant that entered the UK in late 2021. These subvariants are more infectious than the previous variants of the coronavirus that the UK has faced. They are also more likely to cause reinfections. Other factors increasing the number of infections include greater mixing of people now that Covid-19 measures in the UK have ended and reduced protection from infection from vaccines because many people are more than six months since their last Covid-19 vaccination.

Are the new variants worse than the other variants?

Although they are more infectious than other variants, the new subvariants of Omicron do not cause more severe disease and on average, they probably cause a milder illness. However, because of the very large number of infections caused by these subvariants, some people will have a serious illness with a risk of being admitted to hospital or dying. The good news though is that vaccines still work very well at reducing the risk of serious illness and death. The number of deaths from Covid-19 in England is very low due to this protection given by vaccines.

How bad could this new wave get?

We will see a further increase in cases and hospitalisations during July. After July, we should see a decline in both cases and hospitalisations as we saw with the previous two Omicron waves in January and April. Although we will see additional pressures on the NHS, the number of deaths will remain much lower than in January 2021 when deaths from Covid-19 in the UK peaked.

Could any restrictions be brought back and if so, what?

It’s very unlikely the government will bring in any new legal restrictions but they may offer public health advice on the use of face masks in indoor settings and the importance of good ventilation in reducing the risk of infection. They will also encourage people to take up the offer of Covid-19 vaccination if they are eligible for a booster or have not yet had a full course of vaccines.

Wasn’t the colder season the worst time for Covid? How come it’s now spreading in the hot weather?

Respiratory infections are usually worse in winter when the weather is colder and people spend more times indoors. With Covid-19, however, we have seen new virus variants emerge that are highly infectious and which can increase the number of infections, including in the summer.

If I’ve already had Covid this year am I just as likely to catch this new variant, or if I do might the symptoms be milder?

People who have already had an infection this year are less likely to get a second infection. If they do get a second infection, it is likely to be milder, particularly if they are fully vaccinated. However, for some people, a second infection can be more severe than their first infection.

How could the new Covid surge affect the summer holidays?

The UK government has no plans to introduce restrictions on travel or requirements for Covid-19 testing like those we saw in previous years. However, if there is a large increase in the number of Covid-19 infections, it is possible some countries may introduce new measures. However, at this point, I would say this is unlikely to happen.

Will they bring back airport testing, and if not how easily could we catch Covid if there are positive people on the flight?

There are no plans to bring back Covid-19 testing before flights. It’s unlikely this will happen in the UK unless the number of serious Covid-19 cases become so high, the NHS is unable to cope. The best way to prevent this from happening is for everyone to be fully vaccinated. The risks of catching Covid-19 are probably higher in crowded airport terminals than on an airplane because of the ventilation and air filtration systems that modern airplanes use. If people are unwell, they should avoid travelling so that they do not infect others.

I’m back to working next to others in a busy office. What precautions should I take?

Try to ensure that the room is well ventilated. Ideally, everyone in the office should be fully vaccinated. You can also wear a face mask (preferably an FFP2 mask that provides better protection). If anyone is unwell with a possible Covid-19 infection, they should stay at home and not come into work. Employers have a duty of care to their staff and should not ask employees to come to work if they are unwell and may pass on a Covid-19 infection to others.

Am I still protected by the vaccine and booster?

If you are fully vaccinated, including with a booster, you are still very well protected against serious illness and death, although you can still be infected. When another booster is offered in the Autumn, you should take up this offer if you are in an eligible group.

When will another booster be available for people under 75 and will it be updated to protect against the new variant?

Another Covid-19 vaccine booster will be available in the Autumn. This will be offered to people living in care home for older adults and their staff. Frontline health and social care workers and people aged 65 years and over will also be eligible for a booster in the Autumn. Some adults aged 16 to 64 years who are in a clinical risk group will also be eligible for a booster but the government has not yet confirmed what medical conditions will make people eligible. There are now updated vaccines being tested that target Omicron. The government has not yet approved these updated vaccines for use in the UK but if the results from clinical studies are good, it’s very likely these vaccines will be offered in place of the original vaccines for the Autumn booster programme.

Why is there talk of an even worst Covid wave in the Autumn? What might happen?

We had a very high number of hospitalisations and deaths from Covid-19 in the winter of 2020-21. In the winter of 2021-22, thanks to vaccines, the number of hospitalisations and deaths was much lower. It’s very likely that the UK will experience another wave of Covid-19 in the Autumn and Winter when the weather is cooler and people spend more time indoors. This increase in Covid-19 cases may occur at the same time as a large flu epidemic. To reduce the impact of flu and Covid-19 on people’s health and the NHS, it’s essential that eligible people take up the offer of a flu vaccine and that as many people as possible are fully vaccinated against Covid-19, including with any boosters that are offered later this year.

A version of this article was first published in the Daily Mirror.

Impact of COVID-19 on primary care contacts with children and young people in England

During the COVID-19 pandemic, health systems globally shifted towards treating COVID-19 infection in adults and minimising use of health services for other patients, including children and young people (CYP), who were less susceptible to severe COVID-19. In March 2020, the NHS recommended remote triaging before any face-to-face contact to reduce infection risk.

The UK Government announced a nationwide lockdown in England from 23 March 2020, and the public was advised to stay at home to limit transmission of COVID-19 and avoid strain on health resources. GPs were asked to prioritise consultations for urgent and serious conditions, and suspend routine appointments for planned or preventive care.

Children’s access to primary care is highly sensitive to health system changes. We examined the impact of COVID-19 on GP contacts with children and young people (CYP) in England. We used a longitudinal trends analysis was undertaken using electronic health records from the Clinical Practice Research Datalink (CPRD) database.

GP contacts fell 41% during the first lockdown compared with previous years. Children aged 1–14 years had greater falls in total contacts (≥50%) compared with infants and those aged 15–24 years. Face-to-face contacts fell by 88%, with the greatest falls occurring among children aged 1–14 years (>90%). Remote contacts more than doubled, increasing most in infants (over 2.5-fold). Total contacts for respiratory illnesses fell by 74% whereas contacts for common non-transmissible conditions shifted largely to remote contacts, mitigating the total fall (31%).

In conclusion, CYP’s contact with GPs fell, particularly for face-to-face assessments. This may be explained by a lower incidence of respiratory illnesses because of fewer social contacts; changing health-seeking behaviour; or a combination of both. The large shift to remote contacts mitigated total falls in contacts for some age groups and for common non-transmissible conditions.

The study can be read in the British Journal of General Practice.

Long term implications of Covid-19 in pregnancy

An article published in the BMJ by Allyah Abbas-Hanif, Neena Modi and myself discusses the long term implications of Covid-19 in pregnancy. Covid-19 in pregnancy increases the risk of severe complications for both mother and baby. The long term implications are unknown, but emerging signals warn of substantial public health threats. To counter high vaccine hesitancy in pregnancy we must end the default exclusion of pregnant women from the rigorous regulated drug development process and implement systematic, long term, population-wide surveillance of infected and non-infected people.

The full article can be read in the British Medical Journal.

The future of the Covid-19 pandemic in the UK – the essential role for vaccination

Thanks to Covid-19 vaccination, we have seen a substantial weakening of the link between Covid-19 infections and hospitalisations / deaths in the UK. But we don’t yet know how well this protection from serious illness and death will persist in the longer-term. We are also seeing “vaccine fatigue” set in with many people not keen on booster vaccines.

For the UK, the future challenges will include determining how frequently and in what groups Covid-19 booster vaccines are needed; ensuring a high take-up of vaccinations in all eligible groups; and having vaccines that are updated when necessary to protect against new variants. We have already had one additional booster vaccination programme in the UK this year; which targeted people 75 and over, residents of care homes, and people who are immunocompromised. A larger booster programme is planned for later this year that will target a wider range of people, including NHS staff.

Although some people are very optimistic about the future because of the recent decline in the number of Covid-19 cases, hospitalisations and deaths in the UK, this optimism does depend on maintaining high levels of Covid-19 immunity in the population. This won’t be easy and we will see some areas of the UK and some population groups with low take-up of booster vaccines. We therefore need to ensure that we have a strong vaccine delivery system in place that can work with local communities to ensure a high-take up of vaccination – particularly in the most clinically vulnerable groups at highest risk of serious illness and death.

Other Covid-19 control measures are also important and can be implemented when necessary, but ultimately it is vaccination that will allow UK society to function normally rather than these other measures.