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The government must not ignore the doctors who are gearing up to fight COVID-19- herd immunity is not a defence

95% of surveyed NHS workers have said UK measures are not strong enough to prevent the escalation of COVID-19 as the UK’s chief scientific adviser Sir Patrick Vallence told the UK that herd immunity could be a protective measure against COVID-19.   

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Herd immunity involves a large proportion of the population being immune to an infectious disease, in order to protect the non-immune, this works fantastically with extremely safe vaccinations.  But, it is a terrible idea when we’re talking about a disease that kills 14.8% of those over 80 years of age.

COVID-19 has a high death rate in those who are elderly or who have chronic conditions. Herd immunity would require 60% of the population needing to be infected, this could lead to hundreds of thousands of deaths. The World Health Organization (WHO) has said that letting this virus spread at the expense of the most vulnerable members of the population would represent a moral decay in society.

Every time a death occurs the UK announces that the person was in a high-risk group, this may provide some reassurance for those not in high-risk groups.  But what kind of fear are those in these groups experiencing right now?

The WHO have called on all counties to increase the number of COVID-19 tests that are being undertaken, but the UK is stopping the tests for anyone who isn’t in hospital.  This will underestimate the number of people with the condition, it will also mean that people are not aware if they have the condition or not, this could result in them being less likely to self-isolate to protect others.

Making a deadly mistake

The WHO have been clear that all countries should learn from those who have controlled the virus and follow suit.  In their Daily Media Briefing on 13 March 2020 the WHO warned that countries who look at others who are experiencing large epidemics with the thought that it won’t happen to them, are making a deadly mistake.

The WHO have said that the trajectory of the epidemic in each county will be dependent on the measures that are put in place to deal with this public health emergency.

Government scientific advisors will be taking evidence into account when advising the government of the right action to take, but it seems implausible that the UK is taking the correct response, when the rest of the world appear to be putting more stringent measures into place.

On 13 March 2020 Channel 4 News reported that they had surveyed 961 NHS workers, 94% said they did not feel the UK response had been quick enough in order to prevent the escalation of the virus.  95% said they didn’t feel the measures the UK had implemented were strong enough to prevent the escalation of the virus.

On social media UK doctors are warning each other to look into the death in-service benefit of their NHS pensions.  When the vast majority of healthcare workers who are expected to fight this disease on the frontline disagree with the government, we have to question why the government isn’t listening.

Health care workers must stop declaring the number of seasonal influenza deaths when speaking about COVID-19

I have seen a number of health care practitioners declaring the number of deaths that have occurred from seasonal influenza over various time periods when discussing COVID-19.  The number of deaths that seasonal flu has caused over the last few weeks is higher than the number of deaths from COVID-19.  However, this isn’t because seasonal flu is more dangerous, we know the opposite, we know that the death rate from seasonal flu is around 0.01%.  While the overall death rate from COVID-19 is 3.4% and the death rate is more than 20% for those who are over 80 years of age.

Seasonal influenza is important and we should take steps to prevent it, but it must NOT  be used to falsely reassure the public about COVID-19.  We are worried about what COVID-19 is going to do moving forward, seasonal influenza exists in many different strains and has been around for much longer than COVID-19, which only emerged in December 2019.

In a period of just a few weeks COVID-19 has spread to over 100 counties with over 100,000 cases.  What it has the potential to do moving forward if it cannot be contained is terrifying.  Panic and hysteria are not helpful, but as health care practitioners we have a responsibility to take on board guidance from organizations such as the World Health Organization and ensure that the general public receive accurate information on this threat, in order to understand the importance of taking precautions.

Do not confuse people who are looking to healthcare workers for advice, indicating the number of deaths from seasonal flu produces false reassurance that could have a devastating impact.  In their daily media briefing on 9th March 2020 the World Health Organization have been clear that this could be the first pandemic in history that could be controlled.  Decisive early action can slow down the virus and prevent infections, we must all work together to ensure this happens.

COVID-19 can and must be contained

Professor Chris Whitty has said that we are now in the delay phase as the prospect of containment being a success is optimistic.  However, this goes against the World Health Organization’s advice that the virus can be contained.

We have seen evidence of the virus being contained with new cases in China slowing.  Over the last few days China has reported the lowest numbers of confirmed new cases in the country since January 2020, with data from 5th March 2020 indicating that there were 143 new cases in the country over the previous 24 hours.

In their daily media briefing on 5th March 2020 the World Health Organization told counties not to give up on the containment strategy, highlighting that countries must do everything they can to contain COVID-19 and that this approach required all sectors of the government to be involved alongside the input of the community, public sector and private sector.

The delay strategy requires some of the same approaches as the containment phase, such as case finding and isolation of early cases. With extra options such as closing schools, encouraging home working and reducing large gatherings also on the cards.

The aim of delaying the epidemic is to buy time, there has been some speculation that warmer months could mean the virus is less likely to spread.  But we do not know if the virus is seasonal, the World Health Organization has said that we will only know if this is a seasonal virus over time, but the fact that the virus has spread in hot climates such as Singapore means that transmission may not reduce when the weather heats up.

The government has highlighted that buying time will allow for the testing of drugs and the development of a vaccine, but we know that it’s likely to be around a year for such a vaccine to be developed.

The worry with this new phase, is that it is confusing for members of the public.  We need to send out strong messages to society that this virus must be contained and that everybody has a part to play in this.  This is likely to require short-term sacrifices.

We know that the aggressive approach taken in China worked, the World Health Organization have encouraged all countries to follow suit with China’s strategy which included: looking for cases and contacts, social distancing, hand washing, respiratory etiquette and readying systems.

This is not the time to give up and the government must be firm that containment can occur.

WHO Mission Briefing 4th March 2020

The WHO held a Mission briefing on COVID-19 on 4th March 2020.

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They highlighted that:

Containment of COVID-19 must be the top priority for all countries.  But at the same time, countries should also be preparing for sustained community transmission.  Early, aggressive measures mean that countries can stop transmission and save lives.

They called on all countries to:

  • Educate their populations
  • Expand surveillance
  • Find, isolate and care for every case
  • Trace every contact

The nature of this virus means there is an opportunity to break the chains of transmission and contain its spread.

In the UK the total number of cases rose to 87 with 36 new cases confirmed. All but three had travelled to affected countries or been infected by those who had.  This number is expected to rise and at present the approach remains containment.

COVID-19 update: 3rd March 2020

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Should WHO declare COVID-19 as a pandemic?

COVID-19 is not considered a pandemic at present and labelling the outbreak as a pandemic will not cause a shift in the approach which is currently being taken.  Containment is the right approach at present.

At the moment counties fall into one of the following categories

  1. No cases or few cases, in this situation the best option is aggressive containment of cases
  2. Clusters of cases
  3. Counties where there is transmission occurring in the community

Do sports events need to be cancelled?

If there is evidence of intense transmission within a particular area then social distancing is the right approach, this will lessen risky contact between people in these areas.  If this is the case in an area, then events may need to be cancelled.

Is there a medicine shortage?

There has been some information that medicine shortages may occur due to a restriction on export and due to a reduction in manufacturing in China (this is likely to improve soon).

Medicine restriction is not as concerning as the shortage of personal protective equipment, which healthcare workers need to treat cases.  The WHO are monitoring the situation with medicines.

This information is from the World Health Organisation’s daily media briefing on COVID-19 which took place on 3rd March 2020.

Does fasting result in weight loss?

A study has found that people who restrict their eating to between 10 am and 6 pm and fast for the other 16 hours of the day lose 3% of their body weight.

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The study which was published in the journal: Nutrition and Healthy Aging took 23 obese people who had to meet the following criteria:

  • BMI between 30-45 (this means obese)
  • Aged 25-65 years
  • Not going through the menopause
  • Sedentary to lightly active
  • Stable weight over the last 3 months
  • Non-diabetic
  • No history of heart disease or stroke
  • Non-smoker
  • Not a shift worker
  • Not taking medication for weight loss or to reduce lipid or glucose levels

The people in the study were instructed to only eat in the 8 hour window, but they could eat whatever they wanted and didn’t need to calorie count.  Outside of these hours they were allowed to drink water, black tea, coffee and diet soda.  The researchers took measurements at the beginning and end of the 12 week trial to assess their:

  • Body weight
  • Blood pressure
  • Heart rate
  • Total cholesterol, LDL (bad cholesterol), HDL (good cholesterol) and triglyceride levels
  • Fasting glucose
  • Fasting insulin

These results were compared to 23 individuals who has already taken part in a trial several years ago, between 2011-2015.  They were the control group and had been asked to maintain their weight and not to change their levels of eating or physical activity.

The people in the 8 hour eating group noted down when they started and stopped eating each day.  On average it was found that the participants had been adherent to the strict eating window on six out of seven days a week.

By the end of the trial six people in the fasting group had dropped out, leaving just 17 people who had completed the 12 week study.  Although it should be noted that none of the dropouts said they left due to the diet.

So what happened to these 17 people compared to those in the control group?

  • They ate 300 less calories a day
  • They lost 3% of their body weight
  • Their BMI reduced
  • Their systolic blood pressure dropped by 7 mmHg

Sounds great did anything not improve?

Well some things stayed the same when compared to the control group, including:

  • Macronutrients, cholesterol and fibre intake
  • The amount of steps walked a day
  • Fat mass, lean mass and visceral mass
  • Diastolic blood pressure
  • Heart rate
  • Total cholesterol, LDL, HDL, triglycerides, glucose and insulin

But still weight loss right? Does this mean we should all start fasting… No, not so fast [pun intended]…

There are negatives in this study…

  • Only 17 people followed this eating regime for duration of the 12 week study.
  • The drop out rate was quite high with 1 in 4 who started the diet giving it up.
  • We only know that the participants were adhering to this eating window from their self-reported records, which is not an accurate assessment.
  • The study only looked at healthy obese individuals, therefore it doesn’t represent what would happen if non-obese people took on this eating regime or how it would impact on a obese person who for example had diabetes.
  • The best design for this type of experiment is a randomised control study, where people are randomly allocated to an eating regime.  This was not one of those trials, instead it compared the people who were fasting to those who were in a different study several years beforehand.  In this time the general population’s knowledge of weight control may have shifted and the availability of food and seasons may have been different.
  • The study was short as it only took place over 12 weeks, so we don’t know what would happen in the longer term.

What about those sugar free drinks could they have helped or hindered this weight loss?

People were allowed to drink caffeine in the form of black tea and coffee outside of the fasting hours which can affect the body clock.  The principle of fasting is based on how the daily body clock regulates metabolism.  So while the calories in these drinks are low, the impact on the body clock and therefore metabolism can be significant.  I.e. another reason to cut down on your caffeine intake if you want to try this eating regime out.

Is the 10am- 6pm window the best time to eat if I want to fast for 16 hours a day?

This is a good window for fitting in three meals with a typical 9-5 job, as you can have a late breakfast, early lunch and early evening meal.  However other studies have found that eating larger meals early in the day can produce better weight loss than eating your main meal in the evening.  So more studies are needed to look at the effect of shifting this eating window to earlier in the day .

Vitamin D prevents colds and flus

A meta-analysis published in the British Medical Journal has found vitamin D supplementation cuts the rate of upper respiratory infections people experienced.

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A meta-analysis looks at numerous studies which investigate the same topic and combines the data to look for trends.  This one looked at 25 studies with 10933 participants.  All the studies gave vitamin D to an intervention group and looked at the proportion who experienced one acute respiratory tract infection compared to those taking a placebo.

The studies took place in 14 countries over four continents and included both sexes and those aged from birth to 95 years of age.

The studies gave the dose of vitamin D in different ways

  • Bolus doses given at 1-3 months happened in 7 studies
  • Weekly doses were given in 3 studies
  • Daily doses were administered in 12 studies

The studies followed the participants from 7 weeks to 1.5 years. and all were randomised and double blinded.  This meant the participants and the investigators didn’t know who were in each category.

19 of the 25 trials took blood from participants at the start to check their baseline vitamin D concentration, they ranged from 18.9 – 88.9 nmol/L.

The meta-analysis obtained the raw data from the studies and reassessed it.

Less people taking a vitamin D supplement had a respiratory tract infection

Overall the study found that significantly fewer participants experienced one acute respiratory tract infection if they were taking vitamin D supplementation compared to not taking it.

The authors found that the bolus doses (those given in bigger doses every 1 – 3 months) really weren’t that helpful and if the weekly and daily dosed individuals were assessed alone then it became even more significant.

If you take those who had low vitamin D levels to begin with <25 nmol/L you only need to give 4 people a vitamin D supplement to prevent one person from having a respiratory tract infection.  If vitamin D level was above 25 nmol/L to begin with then this rises to 15 people needing to have the supplement to prevent an infection, but is still a significant result.

It found that side effects from vitamin D are rare.

So why is it that the bolus doses didn’t offer much protection, the study has suggested that if you give somebody a bolus of vitamin D then you are going to see a spike in the vitamin D blood concentration, which could have a knock on effect to the usual body processes that lead to activated vitamin D being made active or degraded.

What are the negatives of the meta-analysis?

The disadvantages of the study were that some data may be missing due to perhaps unpublished data, also some subgroups that were assessed had limited data.

Also, The studies didn’t tend to look at who adhered to taking the vitamin D, this could be a plus as the meta-analysis was an intention to treat study (this means it includes everybody, including those who were given the supplement and chose not to take it).  This means that anybody who replicates this study by taking the vitamin D religiously should see at least the benefit that the study found.

The last issue was that very few of the studies actually confirmed an infection with laboratory confirmation.  However, since these type of infections are normally diagnosed from history and examination, it is unlikely to be a big issue.