Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes COVID-19 and is spread person-to-person through close contact. We aimed to investigate the effects of physical distance, face masks, and eye protection on virus transmission in health-care and non-health-care (eg, community) settings.
Methods
We did a systematic review and meta-analysis to investigate the optimum distance for avoiding person-to-person virus transmission and to assess the use of face masks and eye protection to prevent transmission of viruses. We obtained data for SARS-CoV-2 and the betacoronaviruses that cause severe acute respiratory syndrome, and Middle East respiratory syndrome from 21 standard WHO-specific and COVID-19-specific sources. We searched these data sources from database inception to May 3, 2020, with no restriction by language, for comparative studies and for contextual factors of acceptability, feasibility, resource use, and equity. We screened records, extracted data, and assessed risk of bias in duplicate. We did frequentist and Bayesian meta-analyses and random-effects meta-regressions. We rated the certainty of evidence according to Cochrane methods and the GRADE approach. This study is registered with PROSPERO, CRD42020177047.
Findings
Our search identified 172 observational studies across 16 countries and six continents, with no randomised controlled trials and 44 relevant comparative studies in health-care and non-health-care settings (n=25 697 patients). Transmission of viruses was lower with physical distancing of 1 m or more, compared with a distance of less than 1 m (n=10 736, pooled adjusted odds ratio [aOR] 0·18, 95% CI 0·09 to 0·38; risk difference [RD] −10·2%, 95% CI −11·5 to −7·5; moderate certainty); protection was increased as distance was lengthened (change in relative risk [RR] 2·02 per m; pinteraction=0·041; moderate certainty). Face mask use could result in a large reduction in risk of infection (n=2647; aOR 0·15, 95% CI 0·07 to 0·34, RD −14·3%, −15·9 to −10·7; low certainty), with stronger associations with N95 or similar respirators compared with disposable surgical masks or similar (eg, reusable 12–16-layer cotton masks; pinteraction=0·090; posterior probability >95%, low certainty). Eye protection also was associated with less infection (n=3713; aOR 0·22, 95% CI 0·12 to 0·39, RD −10·6%, 95% CI −12·5 to −7·7; low certainty). Unadjusted studies and subgroup and sensitivity analyses showed similar findings.
Interpretation
The findings of this systematic review and meta-analysis support physical distancing of 1 m or more and provide quantitative estimates for models and contact tracing to inform policy. Optimum use of face masks, respirators, and eye protection in public and health-care settings should be informed by these findings and contextual factors. Robust randomised trials are needed to better inform the evidence for these interventions, but this systematic appraisal of currently best available evidence might inform interim guidance.
Nearly a third of doctors have reported that mental health conditions linked to their work —such as anxiety, depression, and burnout—have been made worse by the covid-19 pandemic, a survey by the BMA has found.
“Proper” and ongoing support should be made available to all NHS staff to help them deal with the effects of work related stresses and anxiety related to covid-19, the BMA said. The association said that its own wellbeing support services have seen a 40% increase in use over the past three months, including from those who are feeling anxious about going to work to face unknown situations.
Doctors and healthcare workers have been painted as “heroes” during the pandemic, said David Wrigley, BMA council deputy chair and wellbeing lead, but he warned, “They are not superhuman. They need to feel able to seek help and that help must be readily available.”
The BMA’s latest tracker survey, conducted between 26 and 28 May, had more than 7000 responses and 2000 personal accounts. It found that 41% of doctors were dealing with depression, anxiety, stress, burnout, emotional distress, or another mental health condition relating to or made worse by their work, and 29% of the 7821 respondents said that these had got worse during the pandemic.
Doctors say that long working hours in unfamiliar settings, having to work in personal protective equipment (PPE) for long periods, worries about accessing adequate PPE, fear of contracting covid-19 and passing it on to their loved ones, seeing many patient deaths, and breaking bad news to bereaved families were all having an impact on their wellbeing.
“I am frequently tearful about all those who have died; continuously fearful of contracting covid-19 and secondarily infecting my family,” one doctor told the BMA, while another said, “Everything at work has been more frustrating and exhausting—like wading through treacle.”
At the same time, the lockdown has meant that doctors have been unable to recharge their batteries; there is no socialising and many have isolated themselves from their families to protect them.
“The fatigue after wearing PPE all day cannot be underestimated. It impacts on what I physically and mentally could do after a shift,” one doctor said. “Seeing people dying, receiving and breaking bad news, no socialising outside work to refresh and recharge—all these factors increased the level of anxiety and depression,” added another.
Wrigley said, “The effects of covid-19 will be felt for a long time, both in terms of the impact on the NHS and the long term mental wellbeing of our staff. Even as the number of cases fall, doctors and their colleagues will continue to feel the pressure.
“Therefore, there must be proper support available to all NHS staff not only during the pandemic, but beyond. Supporting the wellbeing of the health workforce must be a top priority in the long term.” (Source: BMJ)
Public Health England | June 2020 | Disparities in the risk and outcomes of COVID-19
PHE has today (2 June 2020) published a review into how different factors have affected COVID-19 risk and outcomes.
The largest disparity found was by age. Among people already diagnosed with COVID19, people who were 80 or older were seventy times more likely to die than those under Risk of dying among those diagnosed with COVID-19 was also higher in males than females; higher in those living in the more deprived areas than those living in the least deprived; and higher in those in Black, Asian and Minority Ethnic (BAME) groups than in White ethnic groups. These inequalities largely replicate existing inequalities in mortality rates in previous years, except for BAME groups, as mortality was previously higher in White ethnic groups. These analyses take into account age, sex, deprivation, region and ethnicity, but they do not take into account the existence of comorbidities, which are strongly associated with the risk of death from COVID-19 and are likely to explain some of the differences.
When compared to previous years, we also found a particularly high increase in all cause deaths among those born outside the UK and Ireland; those in a range of caring occupations including social care and nursing auxiliaries and assistants; those who drive passengers in road vehicles for a living including taxi and minicab drivers and chauffeurs; those working as security guards and related occupations; and those in care homes. These analyses do not take into account the existence of comorbidities, which are strongly associated with the risk of death from COVID-19 and could explain some of these differences.
When this data was analysed, the majority of testing had been offered to those in hospital with a medical need. Confirmed cases therefore represent the population of people with severe disease, rather than all of those who get infected. This is important because disparities between diagnoses rates may reflect differences in the risk of getting the infection, in presenting to hospital with a medical need and in the likelihood of being tested.
Some analyses outlined in this review are provisional and will continue to be improved. Further work is planned to obtain, link and analyse data that will complement these analyses. Disparities in the risk and outcomes from COVID-19 The results of this review need to be widely discussed and considered by all those involved in and concerned with the national and local response to COVID-19. However, it is already clear that relevant guidance, certain aspects of recording and reporting of data, and key policies should be adapted to recognise and wherever possible mitigate or reduce the impact of COVID-19 on the population groups that are shown in this review to be more affected by the infection and its adverse outcomes.
As the numbers of new COVID-19 cases decrease, monitoring the infection among those most at risk will become increasingly important. It seems likely that it will be difficult to control the spread of COVID-19 unless these inequalities can be addressed.
Age and sex
COVID-19 diagnosis rates increased with age for both males and females. When compared to all cause mortality in previous years, deaths from COVID-19 have a slightly older age distribution, particularly for males.
Working age males diagnosed with COVID-19 were twice as likely to die as females. Among people with a positive test, when compared with those under 40, those who were 80 or older were seventy times more likely to die. These are the largest disparities found in this analysis and are consistent with what has been previously reported in the UK. These disparities exist after taking ethnicity, deprivation and region into account, but they do not account for the effect of comorbidities or occupation, which may explain some of the differences.
Geography The regional pattern in diagnoses rates and death rates in confirmed cases among males were similar. London had the highest rates followed by the North West, the North East and the West Midlands. The South West had the lowest. For females the North East and the North West had higher diagnosis rates than London, while London had the highest death rate.
Local authorities with the highest diagnoses and death rates are mostly urban. Death rates in London from COVID-19 were more than three times higher than in the region with the lowest rates, the South West. This level of inequality between regions is much greater than the inequalities in all cause mortality rates in previous years. Disparities in the risk and outcomes from COVID-19 6 Deprivation People who live in deprived areas have higher diagnosis rates and death rates than those living in less deprived areas. The mortality rates from COVID-19 in the most deprived areas were more than double the least deprived areas, for both males and females. This is greater than the inequality seen in mortality rates in previous years, indicating greater inequality in death rates from COVID-19.
High diagnosis rates may be due to geographic proximity to infections or a high proportion of workers in occupations that are more likely to be exposed. Poor outcomes from COVID-19 infection in deprived areas remain after adjusting for age, sex, region and ethnicity, but the role of comorbidities requires further investigation.
Ethnicity People from Black ethnic groups were most likely to be diagnosed. Death rates from COVID-19 were highest among people of Black and Asian ethnic groups. This is the opposite of what is seen in previous years, when the mortality rates were lower in Asian and Black ethnic groups than White ethnic groups. Therefore, the disparity in COVID-19 mortality between ethnic groups is the opposite of that seen in previous years.
An analysis of survival among confirmed COVID-19 cases and using more detailed ethnic groups, shows that after accounting for the effect of sex, age, deprivation and region, people of Bangladeshi ethnicity had around twice the risk of death than people of White British ethnicity. People of Chinese, Indian, Pakistani, Other Asian, Caribbean and Other Black ethnicity had between 10 and 50% higher risk of death when compared to White British.
These analyses did not account for the effect of occupation, comorbidities or obesity. These are important factors because they are associated with the risk of acquiring COVID-19, the risk of dying, or both. Other evidence has shown that when comorbidities are included, the difference in risk of death among hospitalised patients is greatly reduced.
Occupation A total of 10,841 COVID-19 cases were identified in nurses, midwives and nursing associates registered with the Nursing and Midwifery Council. Among those who are registered, this represents 4% of Asian ethnic groups, 3.1% of Other ethnic groups, 1.7% of White ethnic groups and 1.5% of both Black and Mixed ethnic groups. This analysis did not look at the possible reasons behind these differences, which may be driven by factors like geography or nature of individuals’ roles. Disparities in the risk and outcomes from COVID-19.
ONS reported that men working as security guards, taxi drivers and chauffeurs, bus and coach drivers, chefs, sales and retail assistants, lower skilled workers in construction and processing plants, and men and women working in social care had significantly high rates of death from COVID-19. Our analysis expands on this and shows that nursing auxiliaries and assistants have seen an increase in all cause deaths since 2014 to 2018. For many occupations, however, the number of deaths is too small to draw meaningful conclusions and further analysis will be required.
Inclusion health groups When compared to previous years, there has been a larger increase in deaths among people born outside the UK and Ireland. The biggest relative increase was for people born in Central and Western Africa, the Caribbean, South East Asia, the Middle East and South and Eastern Africa. This may be one of the drivers behind the differences in mortality rates seen between ethnic groups.
There were 54 men and 13 women diagnosed with COVID-19 with no fixed abode, likely to be rough sleepers. We estimate that this represents 2% and 1.5% of the known population of women and men who experienced rough sleeping in 2019. Data is of poor quality, but this suggests a much higher diagnoses rate when compared to the general population.
People in care homes Data from the Office for National Statistics (ONS) shows that deaths in care homes accounted for 27% of deaths from COVID-19 up to 8 May 2020. The number of deaths in care homes peaked later than those in hospital, in week ending 24 April. Our analyses show that there have been 2.3 times the number of deaths in care homes than expected between 20 March and 7 May when compared to previous years, which equates to around 20,457 excess deaths. The number of COVID-19 deaths over this period is equivalent to 46.4% of the excess suggesting that there are many excess deaths from other causes or an under-reporting of deaths from COVID-19.
Comorbidities Among deaths with COVID-19 mentioned on the death certificate, a higher percentage mentioned diabetes, hypertensive diseases, chronic kidney disease, chronic obstructive pulmonary disease and dementia than all cause death certificates. Diabetes was mentioned on 21% of death certificates where COVID-19 was also mentioned. This finding is consistent with other studies that have reported a higher risk of death from COVID-19 among patients with diabetes. This proportion was higher in all Disparities in the risk and outcomes from COVID-19 BAME groups when compared to White ethnic groups and was 43% in the Asian group and 45% in the Black group. The same disparities were seen for hypertensive disease. Several studies, although measuring the different outcomes from COVID-19, report an increased risk of adverse outcomes in obese or morbidly obese people (Abridged from Executive Summary)
Local Government Association | June 2020 | Loneliness, social isolation and COVID-19: practical advice
Intervening early to tackle loneliness and social isolation during the COVID-19 pandemic and beyond will help to prevent more costly health and care needs from developing, as well as aiding community resilience and recovery. This can only be done at the local level through partnerships between the council, voluntary and community sector, councillors, primary care networks and relevant others. Councils have a key role to play in this, because they own most of the assets where community action could or should take place, such as parks, libraries and schools, with councillors creating the localised neighbourhood partnerships to deal with a range of mental and physical health issues. There is also an opportunity to harness and develop the positive changes that we are seeing, such as greater awareness about the impact of personal behaviours on mental wellbeing.
Hartmann-Boyce, J. et al. Centre for Evidence-Based Medicine, University of Oxford|June 2020 | Asthma and COVID-19: risks and management considerations
BACKGROUNDPeople with asthma (PWA) have been identified as being at increased risk of serious illness from COVID-19. Understanding this risk and best ways to mitigate it is key to enabling patients, carers, and healthcare professionals to make informed choices about ways to manage asthma during the COVID-19 pandemic.
This rapid review sets out to answer the following questions:
Are PWA at increased risk of contracting COVID-19?
Are PWA at increased risk of worse outcomes from COVID-19?
Are PWA at risk from COVID-19 related disruptions to care?
How should asthma be managed during the COVID-19 pandemic?
How should PWA be managed when presenting with COVID-19?
CURRENT EVIDENCE
Are PWA at increased risk of contracting COVID-19?
As community testing for COVID-19 is still limited, it is impossible to say with any certainty if any groups are more or less likely to contract the disease. Most data on disease prevalence and outcomes come from people hospitalised with COVID-19. At the outset of the pandemic, it was anticipated that people with respiratory diseases, including asthma, would be at higher risk, but emerging data are inconsistent.
In early data on COVID-19 cases (November to February), chronic pulmonary diseases including asthma were ‘surprisingly underrepresented’ (review). A narrative review published on 1st May 2020 noted that the prevalence of asthma in patients with COVID-19 may be lower than expected from population levels, based on both US data and data from China. It is speculated that this may be due to underdiagnosis, poor coding, different immune responses in those with asthma, differences in ACE2 expression, or a protective effect of inhaled corticosteroids. In a prospective observational cohort study of 166 UK hospitals (pre-print, n = 16,749) 14% of patients hospitalised with COVID-19 had asthma (the rate of asthma in the UK population is estimated to be 12%).The Canadian Thoracic Society have issued a position statement that there does not appear to be an increased risk for PWA to acquire COVID-19 infection. The British Thoracic Society states that it remains unclear whether asthma is a risk factor for COVID-19 and COVID-19 related complications. As COVID-19 disproportionately affects older people, the risk of COVID-19 in children with asthma is also unclear.
Data on outcomes in PWA from previous pandemics are also difficult to interpret. PWA appeared under-represented in a review of 473 cases of H1N1 hospitalisations during the 2009 influenza pandemic. In a cohort study (pre-print) from the US and South Korea comparing patients hospitalised with COVID-19 and those hospitalised with influenza from previous years, those hospitalised with COVID-19 had a lower prevalence of asthma compared to those hospitalised with influenza in the US data sources, but higher in the data from South Korea.
Are PWA at increased risk of worse outcomes from COVID-19?
It is unclear whether PWA in general are at increased risk, given the above data showing some instances of under-representation of PWA in those hospitalised with COVID-19. Others have noted it may be difficult to differentiate between COVID-19 symptoms and asthma exacerbations, and that beyond the direct risk of infection itself, there is also a risk of experiencing asthma exacerbations triggered by the virus.
Numerous bodies have identified people with moderate to severe asthma as being at increased risk: the Centers for Disease Control (CDC) state people with moderate to severe asthma are at increased risk of getting very sick from COVID-19; Asthma UK notes a PWA would be considered at very high risk if they were taking extra controller medicines as well as a preventer inhaler and continuous or frequent oral steroids; and the British Thoracic Society notes people taken biologic therapies for severe asthma are considered at very high risk.
A large English cohort study (pre-print, n = 17,425,445, published after previous review), found that asthma was associated with an increased risk of in-hospital death from COVID-19 in both age and sex adjusted and ‘fully adjusted’ (for co-morbidities) models, with risks higher in those with recent oral corticosteroid use (age and sex adjusted HR 1.70 (95% CI 1.48 to 1.96)) compared to those without recent use (age and sex adjusted HR 1.23 (95% CI 1.14 to 1.33). Corticosteroid use can be considered a proxy for disease severity in asthma, so it is unclear if corticosteroid use itself impacts risks from COVID-19 (this is reviewed elsewhere and discussed further below).
Are PWA at risk from COVID-19 related disruptions to care?
Pandemics and national emergencies pose risks to people with long-term conditions because of disruptions in care and disease management. This is reviewed elsewhere, and includes PWA. The possibility that access/adherence to asthma medications may be affected by the current pandemic has been highlighted as an area of concern; exacerbation events and subsequent need for hospitalisation could increase patient exposure to healthcare settings and hence increase risk of infection. A US review of management of asthma in children during the pandemic has noted that the impact of school closures on children with asthma remains to be seen, as schools often have a role in administering asthma medications, and as school closures are speculated to increase the risk of childhood obesity, which is a risk factor for worsening asthma.
How should asthma be managed during the COVID-19 pandemic?
Asthma diagnosis
The diagnosis of asthma is made from a combination of history, examination and supportive tests. Over time, guidelines have placed greater emphasis on objective tests in the diagnostic pathway; a diagnostic algorithm from NICE requires multiple tests to establish asthma diagnosis. These changes over time are important to reduce over- and under-diagnosis, and to look for overlap diseases, e.g. COPD.
This is likely to cause difficulties in the current pandemic. Association for Respiratory Technology and Physiology (ARTP) guidance suggests all respiratory testing is likely to be considered an aerosol generating procedure (AGP) due to its potential to generate coughing, and to assume all patients may have COVID-19. As such, full personal protective equipment (PPE) needs to be worn, with appropriate infection control/air changes.
The capacity to perform testing will be vastly reduced, due to the above measures, combined with reduced staff availability, backlog of tests which have arisen, and ARTP guidance that testing should no longer occur in routine primary care practice (unless part of a coordinated hub). Consultations will also be performed virtually to a much greater degree. It is likely that this will lead to misdiagnosis, forcing clinicians to rely to on history alone to a much greater degree than they would have otherwise.
Use asthma action plans (note weak evidence for these from a 2017 Cochrane review; evidence more positive from a 2017 review specifically looking at written action plans in children)
Use peak flow diaries and consider getting peak flow meter from GP/pharmacist if no current access
Follow standard advice for looking after asthma when unwell
Peak expiratory flow rate (PEFR) can generate a cough and hence become an aerosol-generating procedure (AGP). RCEM guidance in acute exacerbations is only to perform after nebulisation, in those cases where discharge is considered. As mentioned above, ARTP guidance suggests all respiratory testing should be considered an AGP. We did not find any guidance on measurement of exhaled nitric oxide (FeNO).
Multiple questionnaires have been developed to help clinicians in monitoring asthma and related comorbidities, such as the Royal College of Physicians 3 questions, ACQ, ACT, amongst many others. Some of these are more readily available online than others, in part to prevent mis-use where the format of the questionnaire has been mis-transcribed. Patients may lack technical skills/resources to access online even where available, necessitating postal of questionnaires (which may lead to non-return/missing data), or verbal/virtual ‘run-throughs’ of the questionnaires (which may not have been validated for the questionnaire involved).
Medication considerations
All sources reviewed (including NICE in the UK and the CDC in the US) agreed that, on the whole, medications for asthma should continue to be taken as normal. This includes biologics. Prednisone is recommended for treating severe asthma exacerbations.
There is mixed advice on nebulisers with NICE guidance encouraging continued use, a position supported by Public Health England and Health Protection Scotland. A narrative review of managing asthma in children during the pandemic suggests that in most cases children should be switched to other inhaler types, but it is unclear what this advice is based on, a broader narrative review makes the same recommendation, and the Canadian Thoracic Society also warns against their use in certain settings. Concerns with nebulisers relate to the possibility of the devices of aerosolizing the virus if the PWA using the device is infected, therefore increasing risk of contagion. NICE states this is not a concern “because the aerosol comes from the fluid in the nebuliser chamber and will not carry virus particles from the patient”; the British Thoracic Society echoes this. In acute asthma exacerbations, the Royal College of Emergency Medicine (RCEM) suggests consideration of usage of metered dose inhalers (MDI)/spacer for mild/moderate exacerbations, rather than nebulisation, and where nebulisation is used, using minimal flow rate of oxygen required to drive the nebuliser.
Though there has been some debate over the use of inhaled corticosteroids during the COVID-19 pandemic, there is general consensus that their use should not be discontinued (and little evidence of a benefit from introducing them in people in the acute phase of the virus who do not otherwise use them). Some evidence suggests inhaled corticosteroidsmay be of use in treating COVID-19 but this is currently unclear.
Smartinhalers are in development for asthma and COPD; the early evidence is mixed, but they may allow remote monitoring of compliance.
Asthma UK have noted that some PWA have reported issues with accessing medications and suggest if pharmacists can’t provide or source alternative patients ring around other pharmacies or get in touch with their GP. To avoid possible supply issues, NICE recommends medications be prescribed for no more than 30 days; the CDC recommends 30 day supplies of non-prescription medications and supplies.
Healthcare provision
Asthma UK states people should still be getting their same asthma care but some elements “might look different” (i.e. be delivered remotely). They suggest emergency care proceed as normal, GP and specialist care will most likely be via remote means or postponed, and some annual asthma reviews will be postponed.
NICE have issued rapid guidance on severe asthma during the COVID-19 pandemic. Recommendations include:
Communicating with patients and minimising risk by decreasing face-to-face contact where possible
Only carrying out bronchoscopy and most pulmonary function tests for urgent cases where results will have a direct impact on patient care (as these tests may spread COVID-19)
Use of continued and new medications where necessary, with consideration given to training to self-administer and remote monitoring
Advising PWA not to share inhalers or devices and to wash their hands and clean equipment regularly
Local policies to address modifying usual care at organisational level.
Remote care
A reduction in face-to-face appointments is common across countries experiencing COVID-19 pandemics, which will affect asthma care (as already discussed briefly above). Remote care is increasingly being used, but in studies in PWA, remote care is often tested in addition as opposed to instead of face-to-face contact with healthcare providers (HCPs).
In adults, a 2019 systematic review and meta-analysis of telemedicine for asthma (22 studies, 10,281 participants) found tele-case management could significantly improve asthma control compared with usual care (SMD 0.78, 95% CI 0.56 to 1.01). A 2011 systematic review and meta-analysis of telehealth interventions involving healthcare providers (HCPs) in the care of PWA (21 RCTs) did not find clinically important improvements in quality of life or number of visits to the emergency department over 12 months, but did find a significant reduction in the number of patients admitted to hospital once or more over 12 months. The authors concluded telehealth was no better or worse than normal care. This is consistent with a 2016 Cochrane review which found no important differences between face-to-face and remote asthma check-ups in terms of asthma outcomes; however, a lack of information and wide confidence intervals meant the authors could not rule out clinically important differences. A 2015 systematic review found telemedicine interventions did not appear to improve asthma function scores, but concluded “other benefits may be present.” It has been speculated that telehealthcare interventions may be more likely to result in significant benefit in people with severe disease compared to those with relatively mild asthma.
In children and young people, a systematic review (15 studies) found personalised text messaging was the most commonly used digital intervention for asthma care, and that nearly all of the included interventions significantly improved adherence; most also improved health outcomes. In contrast, another systematic review found mixed results for telemedicine in school-aged children, with no evidence of harm, but some studies finding no effect and others finding improvements in health outcomes and adherence. A 2018 review found eHealth tools may be particularly useful for self-monitoring in children and adolescents with asthma.
None of the studies were conducted in the context of reduced healthcare capacity so their relevance to the current pandemic context is unclear.
Self-management
Recommendations that people manage asthma as well as possible during the pandemic may be more challenging due to disruptions posed by the pandemic. A systematic review of 56 studies found the most common themes relating to barriers to asthma self-management included mood disorders and anxiety, social support, and access to healthcare, all of which may be disrupted in the current context.
Self-management and self-education interventions may play a role in asthma control in the context of diminished access to healthcare providers. A 2014 systematic review and meta-analysis of interventions targeting asthma self care in adults (38 trials, 7883 participants) found that interventions targeting asthma self-care reduced symptoms (standardized mean difference −0.38, 95% CI −0.52, −0.24) and unscheduled health care use (odds ratio (OR) 0.71, 95% CI 0.56 to 0.90) and increased adherence to preventive medication (OR 2.55, 95% CI 2.11 to 3.10). The authors were unable to identify what the optimal components of these interventions were, though active involvement of participants was associated with increased effectiveness. Educational programmes have also been found to be effective in children and adolescents (2003 review; 2008 review). A meta-review speculated that digital interventions for asthma may have benefits for people under the age of 65. A separate systematic review concluded that culturally tailored online asthma self-management programmes show promise in difficult-to-reach populations.
A 2018 systematic review found that mobile health interventions for asthma self-management improved asthma control and medication adherence compared to routine care, but results across reviews are mixed. A 2017 systematic review and meta-analysis found that mobile applications improved asthma control (3 studies) but that overall clinical effectiveness varied; authors were unable to identify which components contributed to effectiveness. A 2013 Cochrane review found inconclusive results. A 2018 review found limited evidence that mobile phone apps had a positive effect on asthma self-management in adolescents.
Self-care interventions which have shown promise for asthma control also include decreasing exposure to allergens and pollutants (systematic review, noted general issues with study quality). Systematic reviews differ regarding the effectiveness of air filtration systems, with one finding a positive effect and another not detecting an effect (the included trials were very small). Weight loss in PWA with overweight or obesity may also improve asthma control (systematic review in adults, 10 RCTs; systematic review in adults and children; though issues with the evidence have been noted); obesity has also been identified as a risk factor for COVID-19 severity. Physical activity has been linked with better asthma control, in both children and adults; in people with stable asthma, physical activity interventions of at least 20 minutes, twice a week did not seem to exacerbate symptoms.
Most evidence on self-management in asthma comes from interventions that also involve support from HCPs; though this evidence is broadly positive in showing some benefits and no evidence of harms, it’s relevance to the current pandemic context is unclear. A 2015 review found that, to increase the value of self-management plans in asthma, patients, professionals and organisations all needed to be targeted.
Wellbeing
As noted above, mood disorders and anxiety are barriers to effective asthma control (systematic review). People with asthma have a higher prevalence of anxiety and depression than the general population, which is associated with poorer asthma control, medication adherence, and health outcomes. The pandemic has the potential to exacerbate existing and introduce new mental health issues, with the potential of profound impacts on wellbeing. To manage this, Asthma UK recommends PWA stay active, look after their physical health, stay social, and request support. Several systematic reviews have suggested yoga may improve quality of life in asthma but evidence here is very limited (2016 Cochrane review; 2011 review). Systematic reviews of cognitive behavioural therapy (CBT) in both adults and children found CBT may improve mental health outcomes in PWA, but there were issues with study quality. Systematic reviews have found generally low quality evidence (due to issues with study quality and heterogeneity) for mindfulness-based stress reduction interventions, written emotional disclosure interventions, and relaxation-based therapies in improving wellbeing in PWA, including in both adults and children. In-person psychological therapies will be difficult to access at the current time.
How should PWA be managed when presenting with COVID-19?
Asthma UK provides guidance for what to do for PWA who suspect they may have COVID-19. Considerations specific to PWA include:
If you get an asthma cough and are not sure whether your cough is a symptom of COVID-19 or related to your asthma, talk to a healthcare provider (the British Thoracic Society suggests HCPs let patients know that it is uncommon to get a high temperature, tiredness, and changes in taste or smell with an asthma attack so presence of those symptoms are more likely to suggest COVID-19 infection)
Keep following asthma action plan
Carry on taking all asthma medications as usual
Call 999 for an ambulance if having an asthma attack, and tell them you have COVID-19 symptoms.
A narrative review from the US notes that in early stages there is overlap with asthma and COVID-19 symptoms that only later may progress to more clearly defined COVID-19 symptoms; the same group presents an algorithm suggesting when face-to-face (as opposed to telehealth) evaluation is needed based on COVID risk (high/low) and asthma severity (high/low) or uncertain diagnosis.
There is some advice circulating that ambulance services are advising when assessing PEFR in suspected COVID in PWA in their own home, crews should be at least six feet away and ideally in another room.
For hospitalised patients, a review article presents strategies for aerosol drug delivery to reduce infection risk, and the British Thoracic Society suggests the SPACES approach for delivering ward care (based on the principles of “maximum patient contact – minimum staff exposure”).
CONCLUSIONS
It is unclear if people with asthma are at increased risk of contracting COVID-19 or of worse outcomes from COVID-19 infection. The evidence available is limited with some sources suggesting an underrepresentation of PWA in hospitalised cases, and others showing an increased risk of worse outcomes in PWA which may be associated with disease severity.
Consensus broadly holds that asthma medications should be continued as usual.
Asthma care may be disrupted during the pandemic, self-management and remote interventions may be of benefit but have largely not been tested in this context.
More research is needed on the possible associations between asthma and COVID-19 infection and severity.
More research is also needed on interventions to support asthma care in light of current constraints and disruptions to healthcare systems.
End.
Disclaimer: the article has not been peer-reviewed; it should not replace individual clinical judgement and the sources cited should be checked. The views expressed in this commentary represent the views of the authors and not necessarily those of the host institution, the NHS, the NIHR, or the Department of Health and Social Care. The views are not a substitute for professional medical advice (Source: CEBM)
COVIDSurg Collaborative|Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study |The Lancet |DOI: https://doi.org/10.1016/S0140-6736(20)31182-X
Summary
Background
The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection.
Methods
This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation.
Findings
This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 82·6% (219 of 265) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p<0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p<0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p<0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047).
Interpretation
Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery.
Funding
National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.
Rowland, B. & Kunadian, V. |2020| Challenges in the management of older patients with acute coronary syndromes in the COVID-19 pandemic |Heart| doi: 10.1136/heartjnl-2020-317011
A review published in the BMJ Journal Heart sought to evaluate the challenges and the management strategies in the care of older patients presenting with acute coronary syndromes (ACS) in the context of the COVID-19 pandemic. It finds that edence is sparse on the optimal care of older patients with ACS with lack of robust RCTs.
Abstract
Ischaemic heart disease (IHD), in particular acute coronary syndrome (ACS), comprising ST-elevation myocardial infarction, non-ST-elevation myocardial infarction and unstable angina, is the leading cause of death worldwide. Age is a major predictor of adverse outcome following ACS. COVID-19 infection seems to escalate the risk in older patients with heart disease. Increasing odds of in-hospital death is associated with older age following COVID-19 infection. Importantly, it seems older patients with comorbidities such as cardiovascular disease (CVD), in particular IHD, diabetes and hypertension, are at the highest risk of mortality following COVID-19 infection. The evidence is sparse on the optimal care of older patients with ACS with lack of robust randomised controlled trials. In this setting, with the serious threat imposed by the COVID-19 pandemic in the context of rapidly evolving knowledge with much unknown, it is important to weigh the risks and benefits of treatment strategies offered to older patients. In cases where risks outweigh the benefits, it might not be an unreasonable option to treat such patients with a conservative or a palliative approach. Further evidence to elucidate whether invasive management is beneficial in older patients with ACS is required out-with the COVID-19 pandemic. Though it is hoped that the actual acute phase of COVID-19 infection will be short lived, it is vital that important clinical research is continued, given the long-term benefits of ongoing clinical research for patients with long-term conditions, including CVD. This review aimed to evaluate the challenges and the management strategies in the care of older patients presenting with ACS in the context of the COVID-19 pandemic.
Centre for Evidence-Based Medicine | 28th May 2020
It is unclear if people with asthma (PWA) are at increased risk of contracting COVID-19 or of worse outcomes from COVID-19 infection. The evidence available is limited with some sources suggesting an underrepresentation of PWA in hospitalised cases, and others showing an increased risk of worse outcomes in PWA which may be associated with disease severity.
Consensus broadly holds that asthma medications should be continued as usual. Asthma care may be disrupted during the pandemic; self-management and remote interventions may be of benefit but have not been tested in this context.
This rapid review sets out to answer the following questions:
Are PWA at increased risk of contracting COVID-19?
Are PWA at increased risk of worse outcomes from COVID-19?
Are PWA at risk from COVID-19 related disruptions to care?
How should asthma be managed during the COVID-19 pandemic?
How should PWA be managed when presenting with COVID-19?
Community projects supporting people with their mental health during the coronavirus (COVID-19) pandemic will benefit from their share of £5 million of additional funding | Department of Health and Social Care
Community projects nationwide set to receive share of £5 million government investment to expand mental health support
Cash boost will help existing services respond to global pandemic and protect nation’s wellbeing
Funding to be delivered by mental health charity Mind
Community projects supporting people with their mental health during the coronavirus (COVID-19) pandemic are set to benefit from their share of £5 million of additional funding, Mental Health Minister Nadine Dorries has announced.
Voluntary organisations from across the country – such as local Mind organisations, Ambitious about Autism, Support After Rape and Sexual Violence, LGBT Foundation and Campaign Against Living Miserably – will receive a financial boost to expand their existing support services.
This fund is administered by Mind as part of the Mental Health Consortia, made up of Mind, the Association of Mental Health Providers, Centre for Mental Health, Mental Health Foundation, the National Survivor User Network and Rethink Mental Illness.
European Centre for Disease Prevention and Control | 28 May 2020 | Projected baselines of COVID-19 in the EU/EEA and the UK for assessing the impact of de-escalation of measures
This report from the European Centre for Disease Prevention and Controlaims to provide a short-term 30-day forecast of the expected number of COVID-19 cases, deaths and hospitalised cases (including general hospital ward and intensive care unit) under a set of assumptions.
Executive summary
After widespread transmission of SARS-CoV-2 in EU/EEA countries and the UK over several weeks, the COVID-19 epidemic reached its peak in most countries in April or early May 2020. Some countries have since experienced a sustained decrease in the number of reported cases, progressively reaching the level of transmission reported during the first week of the outbreak. Due to this decrease in transmission and improvements in epidemiological surveillance and healthcare capacity, a number of countries have decided to discontinue several non-pharmaceutical interventions and now plan to gradually phase out their ‘stay-at-home’ policies.
Mathematical modelling of COVID-19 transmission can be used to better analyse the epidemic development in a population over time, produce projections, and inform public health decision-making on interventions. It is particularly useful for the evaluation of public health measures, notably to understand the expected impact of their implementation or release on disease transmission-related indicators. The mathematical modelling approach also allows for the quantification of the uncertainty associated with these estimations and projections. In this report, a dynamic compartmental model of COVID-19 is presented. It aims to provide a short-term 30-day forecast of the expected number of COVID-19 cases, deaths and hospitalised cases (including general hospital ward and intensive care unit) under a set of assumptions. In this first analysis, the baseline scenario corresponds to a ‘status quo’ in which all control measures in place on 2 May 2020 will be continued until the end of the projection period (7 June 2020). The model is based on the epidemiological data and scientific evidence available at the time of publication. Further developments are expected as new information and epidemiological data become available.
The model was developed at ECDC and applied at a national level for EU/EEA countries and the UK. When interpreting predictions of mathematical models for emerging diseases, it is essential to keep in mind the underlying assumptions, limitations and uncertainties resulting from gaps in scientific knowledge and in available data. The inherent sources of uncertainty and the limitations of the mathematical modelling approach taken here are discussed and should be considered when interpreting the results and making comparisons with other mathematical models of COVID-19 transmission.
An assessment of the risk associated with the COVID-19 epidemic and the response strategies applied or envisaged should be based on a comprehensive analysis taking in consideration current uncertainties, the specific epidemiological situation in each country, and outputs of models according to new scientific evidences. Future work in this area intends to promote data sharing and operational forecasting through an ‘ensemble modelling’ approach. This approach combines predictions from different mathematical models to improve on a single‐model forecast, offering more accurate predictions of epidemic trends and clarifying the uncertainties associated with these predictions.
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