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Content developed by Clarity Informatics, providers of online solutions to support the nursing community through appraisals and revalidation.

First published 18 February 2020

Updated 18 May 2020 

INTRODUCTION

The COVID-19 pandemic is dominating the news, our practice and all our thoughts at present, and during the crisis it is important to have access to accurate information so that we understand the context for both Government announcements and reports in the media.

LEARNING OBJECTIVES

This resource will help you to understand:

  • The background to the disease
  • What coronavirus is
  • The scale of the problem
  • The public health response
  • The advice for immunosuppressed and pregnant women
  • The signs and symptoms of COVID-19
  • The responsibilities of individuals, GPs and GPNs, healthcare organisations, the NHS and the government
  • What might happen next
  • Where else to look for help and advice

This resource is provided at an intermediate level by Clarity Informatics. Read the article and answer the self-assessment questions, and reflect on what you have learned.

Complete the resource to obtain a certificate to include in your revalidation portfolio. You should record the time spent on this resource in your CPD log.

Timeline

  • On 8 December 2019 initial descriptions of an unusual pneumonia were reported in Wuhan, Hubei province in China.
  • On 31 December 2019, the World Health Organization was informed by the Chinese authorities that a new type of pneumonia had emerged.
  • From 31 December 2019 to 3 January 2020, 44 case-patients with pneumonia of unknown aetiology were reported to WHO by the national authorities in China, the causal agent was still not identified.
  • On 7 January 2020 The Chinese authorities identified a new type of coronavirus which was causing pneumonia.
  • On 12 January 2020, China shared the genetic sequence of the novel coronavirus for countries to use in developing specific diagnostic kits.
  • Since this time the virus has spread worldwide despite significant attempts at containment.
  • On 12 February 2020, the novel coronavirus was named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) while the disease associated with it is now referred to as COVID-19.

On 11 March the WHO advised that the situation was now a pandemic.1

Background

Previous recent novel disease outbreaks have followed different patterns, but the following table provides a comparison with COVID-19, so far.

Disease Year Number of cases Death rate
SARS 2002-03 8,098 10%
H1N1 (swine flu) 2009 61 million 0.2%*
MERS 2012 – present day 2,494 34%
Ebola 2014-16 26,818 40%
Zika 2015-16 800,000 8.3%

SARS, severe acute respiratory syndrome; MERS, Middle East respiratory syndrome-related coronavirus

*Mortality varied according to the region, but an estimated 205,000 died of H1N1-related illnesses2

In the last 100 years there have been four significant pandemics:

  • Spanish flu (1918-20), estimated to have caused between 25 and 39 million deaths
  • Asian flu (1957-58), estimated to have caused between 1.5 and 4 million deaths
  • Hong Kong flu (1968-69), estimated to have caused between 1 and 4 million deaths
  • Russian flu (1977-78), estimated to have caused 700,000 deaths.3

A typical flu season causes in the region of 400,000 deaths.

WHAT IS CORONAVIRUS?

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a new betacoronavirus. Genetic analysis suggests that bats may be the original host of this virus. It is also thought that an animal from the seafood market in Wuhan could be the intermediate host, leading to the emergence of the virus in humans.

WHAT IS THE SCALE OF THE PROBLEM?

The number of confirmed cases of COVID-19 is increasing daily. This topic will be updated regularly to provide new information as it becomes available in a rapidly changing landscape.

However, Johns Hopkins University have provided an interactive map of the spread of this disease on this publically available site. Coronavirus COVID-19 Global Cases4

At the date of publication there were over 873,767 cases world wide, over 43,288 deaths, and over 184,770 people who had been identified as recovered.

Mortality rates appear to be around 2-3%, with more physically vulnerable people more likely to die from the disease.

The initial outbreak was in mainland China but transmission is now worldwide, with large outbreaks in South Korea, Italy, Iran and the US with varying rates of infection and mortality.

As of 18 May, there were 246,406 confirmed cases in the UK, and 34,796 deaths.

Public Health England has provided a similar interactive map with UK data5

WHAT HAVE BEEN THE PUBLIC HEALTH RESPONSES?

In China extensive efforts aiming to contain the virus have included lock-down of entire cities, with self-quarantine of suspected infected individuals, restrictions on travel and monitoring large swathes of the population.

Beyond the boarders of China, the WHO has coordinated and advised the following measures:

  • Close monitoring for any change in epidemiology
  • Continued intensive source control is needed if there are infections, including isolation of patients and those testing positive for covid-19, contact tracing and health monitoring, and strict health facility infection prevention and control
  • Intensified active surveillance and reporting for in all countries using the WHO case definition
  • Effective communication strategies to provide people (especially those most at risk) with information for protection, recognition of symptoms, and guidance on when and there to seek treatment
  • Resilience preparation for health systems, anticipating the potential for severe infections
  • As a result of widespread community transmission, there has been a move to lockdown across many countries
  • Improved serological tests to estimate current and previous infections exposure
  • Research relating to the source of the outbreak to provide evidence necessary for prevention of future viral infections
  • Research into a potential vaccine6

WHAT ARE THE SYMPTOMS AND SIGNS OF COVID-19?

COVID-19 has a predilection for the upper and lower respiratory tract alveolar cells and is spread by droplets from sneezing and coughing.

The prodrome (pre-illness phase) lasts between 2-10 days. The reason for isolation of 14 days was to ensure a safe return to society to circumvent a slightly longer potential prodrome phase.

In a study of the first 99 patients diagnosed with COVID-19 in China it was found that the majority of people had fever or cough (83%) and a third of patients had shortness of breath.

Other symptoms included muscle ache, headache, confusion, chest pain, and vomiting and diarrhoea (3% and 5%).

Many patients presented with organ function damage, including 17 (17%) with ARDS, eight (8%) with acute respiratory injury, three (3%) with acute kidney injury, four (4%) with sepsis, and one (1%) with ventilator-associated pneumonia.7,8

WHAT IS THE ADVICE FOR PREGNANT WOMEN?

For women who are pregnant and well the advice is to socially distance themselves.

For women who have been exposed to COVID-19 or who have symptoms which are suggestive of COVID-19 the advice is to self-isolate. Now the guidance recommends

  • Not to go to school, work, NHS settings or public areas
  • Not to use public transport
  • To stay at home and do not allow visitors
  • To ventilate the rooms where they are by opening a window
  • To separate themselves from other members of their household as far as possible, using their own towels, crockery and utensils and eating at different times
  • To use friends, family or delivery services to run errands, but advise them to leave items outside9

WHAT IS THE ADVICE FOR PEOPLE WITH IMMUNOSUPPRESSION?

Public Health England9 has issued guidance for people with immunosuppression to undertake self isolation. PHE defines people in the following groups to be at high risk.

Those aged over 70 years of age, or

Aged under the age of 70

and with one of the following conditions

  • Chronic (long-term) respiratory diseases, such as asthma, chronic obstructive pulmonary disease (COPD), emphysema or bronchitis
  • Chronic heart disease, such as heart failure
  • Chronic kidney disease
  • Chronic liver disease, such as hepatitis
  • Chronic neurological conditions, such as Parkinson’s disease, motor neurone disease, multiple sclerosis (MS), a learning disability or cerebral palsy
  • Diabetes
  • People with problems with their spleen such as sickle cell disease or who have had their spleens removed
  • People with a BMI of over 40
  • People with a deficient immune system as the result of conditions such as HIV and AIDS, or medicines such as oral corticosteroids or chemotherapy

WHAT ARE YOUR RESPONSIBILITIES?

As a healthcare worker it is important that you can access and understand the latest advice from Public Health England

Currently the advice given is to:

  • Identify potential cases
  • Prevent transmission
  • Avoid direct physical contact
  • Isolate the patient and obtain specialist advice to determine if the patient is at risk9

Patients are advised to use the 111 online coronavirus service at https://111.nhs.uk/service/covid-19

  • They are being advised not go to a GP surgery, pharmacy or hospital.
  • In Scotland, people are advised to ring their GP or NHS 24 on 111 out of hours. In Northern Ireland, call 0300 200 7885.

WHAT IF A PATIENT ARRIVES AT THE PRACTICE WITH POSSIBLE COVID-19?

NHS England has published a standard operating procedure, which can be found here10 

Current advice from Public Health England is as follows:

  • An unwell patient with a relevant travel history should be identified when they book in at reception and placed in a room away from other patients and staff.
  • If COVID-19 is considered possible when a consultation is already in progress, withdraw from the room, close the door and wash your hands thoroughly with soap and water.
  • Avoid physical examination of a suspected case. The patient should remain in the room with the door closed. Belongings and waste should remain in the room.
  • Advise others not to enter the room. If a clinical history still needs to be obtained or completed, do this by telephone.
  • The patient should not be allowed to use communal toilet facilities. Instruct them to not touch anything or anyone when walking to the toilet. Instruct the patient to wash their hands thoroughly after toileting.
  • Ask the patient to call NHS 111 from their room, on their mobile (they can use GP surgery landline if mobile unavailable).

WHAT ARE YOUR RESPONSIBILITIES IN GENERAL PRACTICE?

When a telephone interview is being conducted with a patient located elsewhere and it determined that COVID-19 is possible (based on the PHE criteria for a possible case).  

Patient transfers

  • If the patient is critically ill and requires an urgent ambulance transfer to a hospital, inform the ambulance call handler of the concerns about COVID-19.
  • In all other instances, the case must be discussed with the hospital first so that they are aware that COVID-19 is being considered and the method of transport to secondary care agreed.
  • Patients with suspected COVID-19 should be instructed not to use public transport or taxis to get to hospital.
  • Following the patient transfer, the room should be closed and should not be used until further advice is provided by the local Health Protection Team (HPT).

WHAT ARE YOUR ORGANISATION’S RESPONSIBILITIES?

If a person with a possible case of COVID-19 has been in a primary care building then a specific approach to cleaning must be undertaken. This includes:

Preparation

  • The responsible person undertaking the cleaning with detergent and disinfectant should be familiar with these processes and procedures:
  • collect all cleaning equipment and clinical waste bags before entering the room
  • any cloths and mop heads used must be disposed of as single use items

before entering the room, perform hand hygiene then put on a disposable plastic apron and gloves

On entering the room

  • Keep the door closed with windows open to improve airflow and ventilation while using detergent and disinfection products
  • Bag all items that have been used for the care of the patient as clinical waste, for example, contents of the waste bin and any consumables that cannot be cleaned with detergent and disinfectant
  • Remove any fabric curtains or screens and bag as infectious linen
  • Close any sharps containers wiping the surfaces with either a combined detergent disinfectant solution at a dilution of 1000 parts per million (ppm) available chlorine (av.cl.) or a neutral purpose detergent followed by disinfection (1000 ppm av.cl.)

Cleaning process

  • Use disposable cloths, paper roll, and disposable mop heads to clean and disinfect all hard surfaces (floors, chairs, door handles, reusable non-invasive care equipment, sanitary fittings) in the room, following one of the two options below:
  • use either a combined detergent disinfectant solution at a dilution of 1000 parts per million (ppm) available chlorine (av.cl.)
  • or a neutral purpose detergent followed by disinfection (1000 ppm av.cl.)
  • follow manufacturer’s instructions for dilution, application and contact times for all detergents and disinfectants
  • any cloths and mop heads used must be disposed of as single use items

Cleaning and disinfection of reusable equipment

  • Clean and disinfect any reusable non-invasive care equipment, such as blood pressure monitors, digital thermometers, glucometers, that are in the room prior to their removal
  • Clean all reusable equipment systematically from the top or furthest away point

Carpeted flooring and soft furnishings

If carpeted floors or item cannot withstand chlorine-releasing agents, consult the manufacturer’s instructions for a suitable alternative to use, following or combined with detergent cleaning.

On leaving the room

  • Discard detergent and disinfectant solutions safely at disposal point
  • All waste from suspected contaminated areas should be removed from the room and quarantined until patient test results are known (this may take 48 hours); if the patient is confirmed to have COVID-19 further advice should be sought from the local health protection team (HPT)
  • Clean, dry and store re-usable parts of cleaning equipment, such as mop handles
  • Remove and discard PPE as clinical waste
  • Perform hand hygiene

Cleaning of communal areas

If a suspected case spent time in a communal area, for example, a waiting area or toilet facilities, then these areas should be cleaned with detergent and disinfectant (as above) as soon as practicably possible, unless there has been a blood/body fluid spill which should be dealt with immediately. Once cleaning and disinfection have been completed, the area can be put back in use.11

WHAT ARE THE WIDER NHS RESPONSIBILITIES?

The NHS as an organisation has a responsibility to coordinate the response to the potential service changes to accommodate any cases or outbreak of COVID-19 in the UK.

The NHS also has a responsibility to collect, learn from and disseminate the most up to date information and learning across primary, secondary, pre-hospital emergency services and tertiary care.

The NHS also has a responsibility to provide guidance on how to improve outcomes and care for patients.

The NHS has an additional responsibility to report statistics for all services.

What are the Government’s responsibilities?

In a time of national need the Government’s first duty is to strive to protect the population.

In doing this, the government has a responsibility to deploy all resources at its disposal, including clinical, technical, financial, organisational and infrastructural.

It will utilise national contingency planning, if needed, in order to coordinate a response which involves elements of containment, monitoring, active treatment, mass communication, research and, if needed, mitigation.

TREATMENT

There is currently no specific treatment for coronavirus. Antibiotics do no work against viruses, and there are no specific antiviral medicines that are effective against this virus. Treatment aims to relieve the symptoms of COVID-19 while the body fights the infection: this may involve ventilation or other respiratory support measures in severe cases.

A number of existing agents are being investigated for use in patients with COVID-19, including

  • Chloroquine (used for the treatment of malaria and rheumatoid arthritis)
  • Lopinavir and ritonavir (Kaletra, a combination of two antiviral agents used to treat HIV)
  • Interferon β1a (currently under investigation in phase II trials for asthma)
  • Remdesivir (an investigational agent that inhibits viral replication)
  • Tocilizumab (monoclonal antibody used in rheumatoid arthritis), and
  • Favipiravir (antiviral drug).12,13

There have been some reports stating that non-steroidal anti-inflammatory drugs (NSAIDs) exacerbate symptoms in COVID-19 patients, but a systematic review found no published evidence for or against their use. There is some evidence that early use of corticosteroids may be beneficial, but this approach is not currently supported by the WHO.14

WHAT MIGHT HAPPEN NEXT?

A global pandemic was declared by WHO on 11 March. Extensive monitoring is being conducted worldwide and disease pattern modelling undertaken by several centres. Many countries have moved to a wide scale lock-down.

The current total is 99.78 cases per million globally but this is still rising.

The current total of death is 4.78 per million, again rising.

In terms of prevention the most useful measures are social distancing for asymptomatic people, isolation for those with symptoms and simple hygiene approaches to coughs and sneezes, including the use of disposable tissues and frequent hand washing.

Paper surgical masks although popular, do not appear to be effective in the prevention of coronavirus dissemination.

WHERE CAN YOU GO FOR MORE HELP AND ADVICE?

The NHS provides a wide range of information and advice on the potential risk of coronavirus for clinicians, administrators, patients and carers.

Public Health England has detailed advice on their website for clinicians, for concerned individuals and travellers.

Clarity https://elearning.clarity.co.uk has further modules on pandemic influenza and the disposal of clinical waste. Clarity can also provide an extensive literature search on request.

This module will be updated regularly to reflect any changes in the evidence base.

REFERENCES

1. World Health Organization. Coronavirus; 2019 https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports

2. Our World in Data https://ourworldindata.org/coronavirus

3. European Centre for Disease Prevention and Control https://www.ecdc.europa.eu/en/novel-coronavirus-china

4. National Institute of Allergy and Infectious Diseases Rocky Mountain Laboratories https://www.niaid.nih.gov/about/rocky-mountain-overview

5. Public Health England https://www.gov.uk/government/news/phe-reaches-crucial-step-in-fully-sequencing-novel-coronavirus

6. WHO Joint Missions Report on Coronavirus Disease https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf

7. Chen N, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020;395(10223):507-513 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30211-7/fulltext

8. Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention. JAMA. Published online February 24, 2020. doi:10.1001/jama.2020.2648 https://jamanetwork.com/journals/jama/fullarticle/2762130

9. Department of Health and Social Care https://www.gov.uk/guidance/wuhan-novel-coronavirus-information-for-the-public

10. NHS England COVID 19 Standard Operating Procedure https://www.england.nhs.uk/wp-content/uploads/2020/02/20200305-COVID-19-PRIMARY-CARE-SOP-GP-PUBLICATION-V1.1.pdf

11. Health and Safety Executive https://www.hse.gov.uk/news/coronavirus.htm

12. Lancet COVID-19 Resource Centre https://www.thelancet.com/coronavirus?dgcid=kr_pop-up_tlcoronavirus20

13. Mahase E. Covid-19: what treatments are being investigated? BMJ 2020;368:m1252 https://www.bmj.com/content/368/bmj.m1252

14. Russell E, Moss C, Rigg A, Van Hemelrijck M. COVID-19 and treatment with NSAIDs and corticosteroids: should we be limiting their use in the clinical setting? ecancer 2020;14:1023 https://ecancer.org/en/journal/article/1023-covid-19-and-treatment-with-nsaids-and-corticosteroids-should-we-be-limiting-their-use-in-the-clinical-setting