Covid-19 update: 8 January

by Steve Brown

08 January 2021

Monday’s move to a national lockdown in England and Scotland, joining Wales and Northern Ireland in the highest level of restrictions, was described as ‘inevitable’ in the face of rising Covid-19 cases and rapidly filling hospitals.

On Monday, a new high for daily cases was recorded, with the 58,784 cases representing a more than 40% increase on the previous week and a four-fold increase on the numbers being reported at the start of December. The increase in positive cases has led to a rise in hospital admissions, which tend to lag positive test results by about two weeks.HFMA Covid-19

In England, the NHS started the year by admitting a record number of Covid patients to hospitals. And by Monday, English hospitals had 26,626 Covid patients in beds, significantly above the levels experienced in the first wave.

NHS Providers chief executive Chris Hopson said that the 9,000 increase in bed occupancy in the 10 days since Christmas was equivalent to 18 hospitals full of new Covid patients. The sharp acceleration in numbers is being attributed, at least in part, to the new variant of the virus, first detected in the UK but which is now being found across the globe. The variant is claimed to be between 50% and 70% more transmissible.

Mr Hopson said the new variant had ‘changed the rules of the game’ and the new national lockdown was ‘the only option to save lives, reduce patient harm and ensure the NHS can safely provide all patients with the care they need’.Danny Mortimer

NHS Confederation chief executive Danny Mortimer (pictured) said that members knew that the national lockdown was ‘inevitable and necessary’. With huge pressure on the NHS across the country and the NHS’s capacity at risk of becoming overwhelmed within the next 21 days – a fear raised by the prime minister in his address to the nation outlining the new restrictions – Mr Mortimer said ‘there was no option other than to take these drastic steps’.

‘The public must help the NHS by following the requirements of social distancing to the letter,’ he added. ‘The virus is not under control and the standards upon which the NHS prides itself are already being weakened and compromised.’

The Health Service Journal reported that a briefing to doctors in London had raised concerns about the capital’s hospitals being overwhelmed within a fortnight, even if Covid admissions grew at the lowest rate considered likely. And reports from the frontline underlined these growing concerns. Rupert Pearse, a London intensive care consultant, speaking on behalf of the Intensive Care Society to BBC Radio 4’s Today programme on Thursday, said the current situation was worse than the first wave and proving much harder to deal with as the same resources weren’t available to hospitals and staff were increasingly overstretched.

‘We would normally want one fully trained intensive care nurse per intensive care patient,’ he said. ‘Right now we are diluting down to one nurse to three and filling those gaps with untrained staff and, in some cases, doctors helping nurses to deliver their care. But we are now even facing diluting that further to one in four. And, as intensive care doctors, we are not sure how together we can deliver the quality of care that we need to.’ He added that the challenges were not confined to London or just to intensive care.

Latest figures from the Office for National Statistics’ coronavirus infection survey suggest that in the week to 2 January, 2% of the population had the virus – a sobering one in 50 people. This ranged from one in 30 in London to one in 125 in the South West, but with infection levels in the North West and East Midlands (both one in 40) causing real concern.

Winter update

Numbers continued to worsen through the week, with Wednesday seeing a further 1,041 deaths reported alongside 62,322 new cases and more than 30,000 Covid patients in UK hospitals. The seriousness of the situation was underlined by the release of the latest winter reporting data from NHS England and NHS Improvement, which showed hospitals already operating at near full capacity with demand still rising.

NHS Providers’ Chris Hopson said the pressure on bed occupancy was having significant knock-on effects throughout the system. ‘Ambulance arrivals increased by nearly 6% this week and handover delays for patients arriving by ambulance increased steeply, with 16% of patients delayed by 30 minutes or more and nearly 6% delayed by over an hour,’ he said. ‘Every handover delay equates to a crew that can’t respond quickly to other emergency calls where they are desperately needed.

‘Trust leaders are telling us these pressures are being felt across the system, with mental health, community as well as in primary and social care settings similarly feeling the brunt of winter and Covid-19 pressures.’

However, health secretary Matt Hancock told a House of Commons debate that the difference between the current situation and the first wave was that ‘we now know what the way out looks like’. In particular, he was referencing the roll-out of the vaccination programme.

On Tuesday, the prime minister provided an update on the programme to date, with 1.3 million people across the UK having received their first dose of a Covid vaccine. This included 23% of all over-80s and he set a mid-February target for vaccinating everybody in the top four priority groups identified by the Joint Committee on Vaccination and Immunisation. These groups cover care home residents and their carers, frontline health and social care workers and everyone over 70 – totalling some 15 million people across the UK. This would require the NHS to increase vaccination rates to around two million per week.

In a further update on Thursday, ahead of daily vaccination updates starting next week, Mr Johnson said that the number of people to have now received their first dose had risen to 1.5 million – 1.26 million in England, 113,000 in Scotland, 49,000 in Wales and 46,000 in Northern Ireland.

Both currently usable vaccines – Pfizer BioNTech and the more recently approved Oxford/AstraZeneca – officially require two doses for full immunity. However, the UK has taken the decision to delay second doses (up to 12 weeks after the first dose) to enable more people to receive a first dose faster.

Earlier in the week, England’s chief medical officer Chris Whitty said this meant the number of people vaccinated could be doubled over three months. ‘If over that period there is more than 50% protection then you have actually won,’ he said. ‘More people will have been protected than would have been otherwise. Our quite strong view is that protection is likely to be a lot more than 50%.’

On Friday, the Department of Health and Social Care announced that a third vaccine – produced by Moderna – has been authorised for use by the Medicines and Healthcare Products Regulatory Agency. The vaccine, which is 94% effective, will begin to be delivered to the UK from the spring and the government has ordered 17 million doses.

Labour leader Keir Starmer called on the government to use the lockdown to establish a round-the-clock vaccination programme. And shadow health secretary Jonathan Ashworth said that the ambition should be to exceed two million vaccinations a week. ‘Surely our long-term aim should be to scale up to three, then five, then six million jabs a week,’ he told Wednesday’s Commons debate on the lockdown measures. ‘If we can vaccinate 29.6 million people, deaths and hospitalisation will be reduced by 99%. We should be targeting that now.’Andrew.Lane P

Pharmacy role

The government has faced specific criticism for not making greater use of community pharmacies with their experience of delivering annual flu jabs. National Pharmacy Association chair Andrew Lane (pictured) said pharmacies were well equipped to get started immediately. ‘The vast majority of pharmacies provide flu vaccinations, so there are thousands of potential local pharmacy sites for vaccinating against Covid, capable of protecting millions of people within weeks,’ he said. ‘We are bound to ask, what on earth is stopping the NHS from mobilising more pharmacies for this vital task?’

However, speaking at Thursday’s government briefing, Mr Johnson said that a ‘first wave’ of 200 community pharmacies were already part of planned capacity. More than 700 GP-led vaccination sites were already in operation – although it was reported that some GP practices did not receive their batches of vaccine in time for Thursday’s planned roll-out – and this would rise to 1,000 by the end of next week. This would be on top of the existing 200 plus hospital hub sites and supplemented by an additional seven major vaccination sites – including sports stadiums and exhibition centres.  

NHS chief executive Simon Stevens, also speaking at Thursday’s briefing, acknowledged the reported success of Israel’s vaccination programme, which has been built around the setting up of large-scale vaccination centres.  ‘We are trying to get the balance right between the scale efficiencies you get from some of these larger centres, combined with the local convenience of the options through your local GPs and, overtime, from pharmacists as well,’ he said. ‘We think that, given the geography of this country, actually having a mixture of these different routes will be the right answer.’

The prime minister added that with all the sites working, there should be enough capacity to deliver hundreds of thousands of vaccines per day by 15 January. ‘And it is our plan that everybody should have a vaccination available within a radius of 10 miles,’ he said.

The Oxford/AstraZeneca vaccine can be stored and transported at fridge temperatures, making it well suited for use in care homes and other small sites. However, the more-difficult-to-handle Pfizer/BioNTech vaccine – which needs to be transported and kept at hyper-cold temperatures – is now also being issued to local vaccination services in smaller packs that can be used in care homes.

Vaccinations are not the only weapon in the battle against coronavirus. It has been said many times that the NHS now knows its enemy better and treatments have improved. Patients have been able to be treated more on wards, rather than moving to intensive care in many cases.

Treatment options

Anti-inflammatory drug dexamethasone has been approved for hospitalised Covid patients requiring oxygen, reducing the risk of death by as much as 35% for patients on ventilation. The anti-viral drug remdesivir has also been identified as a Covid-19 treatment in certain circumstances, with studies suggesting it reduces the need for mechanical ventilation and improves recovery time for hospitalised patients.

And this week, two new treatments have been made ‘immediately available’ for patients in intensive care units. Results from a government-funded clinical trial showed tocilizumab and sarilumab reduced the relative risk of death by 24% when administered to patients within 24 hours of entering intensive care. The drugs, which are normally used for rheumatoid arthritis, cut the time patients spent in intensive care by between seven and 10 days. And their rollout is seen as helping to reduce pressures on hospitals.

A new report from the Getting it Right First Time – Clinical practice guide for improving the management of adult COVID-19 patients in secondary care – has now pulled together good practice from high performing trusts that responded well to the pandemic. The guide highlights shared learning: in infection control; emergency medicine; critical care and anaesthesia; acute and general medicine; respiratory medicine; geriatric and community care; and diabetes. It also explores a number of cross-cutting themes.

There have also been further reminders about the continued importance of testing and tracing – with more emphasis on isolation and support for isolation – in getting the country out of the pandemic.

The latest report from the NHS Test and Trace service in England said that just over 311,000 people tested positive for the virus in the week to 30 December – a 24% increase on the previous week – and nearly 270,000 people were transferred to the contact tracing system. Of these 85% were reached and 80% of these provided details of 494,000 close contacts. Some 92% of these were contacted and asked to self-isolate (for households, only one member needs to be contacted for everyone to be counted as ‘contacted’). For all test routes, results for some 19% of tests undertaken in the community were delivered within 24 hours. And just 33% of in-person test results achieved the 24-hour target.layla.mccay p

Dr Layla McCay (pictured), director at the NHS Confederation, said the figures showed how rapidly the virus had been spreading – and this was before the full effects of additional household mixing over Christmas could be seen.

She also raised concerns about the changes in the method for reporting whether whole households had been asked to self-isolate. ‘It is worrying that the true figure for close contacts reached and asked to self-isolate is masked by the fact that under-18s and other adults in the same household are no longer included. If we do not have the full picture, we cannot know how effective the system is,’ she said.

‘The NHS is very close to breaking point. Until the vaccine has been more widely rolled out, the most effective way to [protect the NHS] is to keep social contact to the absolute minimum.’

Scientific advice

One of the criticisms levelled at the government throughout the pandemic response has been a perceived tardiness in decision making. These have continued recently with numerous commentators pointing at delays in moving to full national lockdown in the face of rapidly rising cases. This compares, for example, with Brisbane’s announcement this week of a three-day lockdown after finding a single case of the new coronavirus variant.

The UK was also slow to introduce restrictions on travellers coming into the UK in the first wave and has only this week announced plans to require international passengers to have a negative test before travelling to the UK. This has been motivated by concerns over the new South African coronavirus variant entering the country. Other countries have had testing requirements in place for months as a means of reducing required quarantine periods.

The government has claimed that it has ‘followed the science’ in making all its key decisions. This week the Commons Science and Technology Committee gave its assessment of how this advice had been used during the first period of the pandemic.

It praised the work of UK scientists and the science community in general, highlighting in particular the rapid development of vaccines. The committee found that the government had been serious about taking and following advice from scientists of international repute. There had been improvement since an initial lack of transparency around the evidence being drawn on, although more openness was needed.

But The UK response to Covid-19: use of scientific advice also said that a fully effective response to the pandemic had been hampered by a lack of data, due to insufficient testing capacity in the early days.

‘Although the government was advised by many experts of distinction, and generally followed the advice that was given, the outcome during the first wave of the pandemic is not regarded as having been one of the best in the world,’ the report said. ‘While the experience of no country is perfectly comparable with others, it will be important to understand the reasons for this in order to learn lessons for the future.’